| VCA Upper Limb Candidate Listing Registration |
| Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
| Waitlist registration > Provider |
Transplant hospital |
Display Only – Cascades from Database |
| Waitlist registration > Provider |
24 hour contact phone number |
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| Waitlist registration |
Organ registration |
Display Only – Cascades from Database |
| Waitlist registration > Candidate identification |
SSN |
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| Waitlist registration > Candidate identification |
Confirm SSN |
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| Waitlist registration > Candidate identification |
Date of birth |
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| Waitlist registration > Candidate identification |
Confirm date of birth |
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| Waitlist registration > Candidate identification |
Center patient ID |
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| Demographics |
Last name |
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| Demographics |
First name |
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| Demographics |
MI |
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| Demographics |
Birth sex |
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| Demographics |
State of permanent residence |
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| Demographics |
Permanent ZIP code |
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| Demographics |
Ethnicity |
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| Demographics |
Race |
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| Organ information |
Candidate medical urgency status |
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| Organ information |
Inactive reason |
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| Organ information |
Number of previous VCA - upper limb transplants |
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| Organ information |
VCA body part(s) |
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| Organ information |
Skin type |
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| Clinical data |
Blood type |
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| Clinical data |
Height (cm) |
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| Clinical data |
Height (ft) |
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| Clinical data |
Height (in) |
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| Clinical data |
Weight (kg) |
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| Clinical data |
Weight (lbs) |
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| Clinical data |
Select any additional organs the candidate may need |
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| HLA and unacceptable antigens > HLA CLASS I |
A |
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| HLA and unacceptable antigens > HLA CLASS I |
A |
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| HLA and unacceptable antigens > HLA CLASS I |
B |
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| HLA and unacceptable antigens > HLA CLASS I |
B |
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| HLA and unacceptable antigens > HLA CLASS I |
BW4 |
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| HLA and unacceptable antigens > HLA CLASS I |
BW6 |
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| HLA and unacceptable antigens > HLA CLASS I |
C |
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| HLA and unacceptable antigens > HLA CLASS I |
C |
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| HLA and unacceptable antigens > HLA CLASS II |
DR |
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| HLA and unacceptable antigens > HLA CLASS II |
DR |
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| HLA and unacceptable antigens > HLA CLASS II |
DR51 |
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| HLA and unacceptable antigens > HLA CLASS II |
DR51 |
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| HLA and unacceptable antigens > HLA CLASS II |
DR52 |
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| HLA and unacceptable antigens > HLA CLASS II |
DR52 |
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| HLA and unacceptable antigens > HLA CLASS II |
DR53 |
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| HLA and unacceptable antigens > HLA CLASS II |
DR53 |
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| HLA and unacceptable antigens > HLA CLASS II |
DQB1 |
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| HLA and unacceptable antigens > HLA CLASS II |
DQB1 |
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| HLA and unacceptable antigens > HLA CLASS II |
DQA1 |
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| HLA and unacceptable antigens > HLA CLASS II |
DQA1 |
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| HLA and unacceptable antigens > HLA CLASS II |
DPB1 |
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| HLA and unacceptable antigens > HLA CLASS II |
DPB1 |
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| HLA and unacceptable antigens > HLA CLASS II |
DPA1 |
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| HLA and unacceptable antigens > HLA CLASS II |
DPA1 |
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| HLA and unacceptable antigens > Confirm HLA CLASS I |
A |
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| HLA and unacceptable antigens > Confirm HLA CLASS I |
A |
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| HLA and unacceptable antigens > Confirm HLA CLASS I |
B |
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| HLA and unacceptable antigens > Confirm HLA CLASS I |
B |
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| HLA and unacceptable antigens > Confirm HLA CLASS I |
BW4 |
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| HLA and unacceptable antigens > Confirm HLA CLASS I |
BW6 |
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| HLA and unacceptable antigens > Confirm HLA CLASS I |
C |
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| HLA and unacceptable antigens > Confirm HLA CLASS I |
C |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DR |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DR |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DR51 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DR51 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DR52 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DR52 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DR53 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DR53 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DQB1 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DQB1 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DQA1 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DQA1 |
|
| HLA and unacceptable antigens > Confirm HLA CLASS II |
DPB1 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DPB1 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DPA1 |
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| HLA and unacceptable antigens > Confirm HLA CLASS II |
DPA1 |
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| HLA and unacceptable antigens > Unacceptable antigens |
A |
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| HLA and unacceptable antigens > Unacceptable antigens |
B |
|
| HLA and unacceptable antigens > Unacceptable antigens |
BW |
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| HLA and unacceptable antigens > Unacceptable antigens |
C |
|
| HLA and unacceptable antigens > Unacceptable antigens |
DR |
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| HLA and unacceptable antigens > Unacceptable antigens |
DR51 |
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| HLA and unacceptable antigens > Unacceptable antigens |
DR52 |
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| HLA and unacceptable antigens > Unacceptable antigens |
DR53 |
|
| HLA and unacceptable antigens > Unacceptable antigens |
DQB1 |
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| HLA and unacceptable antigens > Unacceptable antigens |
DQA1 |
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| HLA and unacceptable antigens > Unacceptable antigens |
DPB1 - unacceptable antigens |
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| HLA and unacceptable antigens > Unacceptable antigens |
DPB1 - unacceptable epitopes |
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| HLA and unacceptable antigens > Unacceptable antigens |
DPA1 |
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| Donor type > Infectious diseases |
Accept a Hepatitis B core antibody positive donor? |
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| Donor type > Infectious diseases |
Accept an HBV NAT positive donor? |
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| Donor type > Infectious diseases |
Accept an HCV antibody positive donor? |
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| Donor type > Infectious diseases |
Accept an HCV NAT positive donor? |
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| Donor type > HOPE Act IRB Research |
Is the candidate HIV positive and willing to accept an HIV positive VCA - upper limb? |
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| Donor type |
Accept DCD donor? |
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| Donor characteristics |
Minimum acceptable donor age |
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| Donor characteristics |
Minimum acceptable donor age (unit) |
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| Donor characteristics |
Maximum acceptable donor age |
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| Donor characteristics |
Maximum acceptable donor age (unit) |
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| Donor characteristics |
Minimum acceptable donor height |
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| Donor characteristics |
Minimum acceptable donor height (unit) |
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| Donor characteristics |
Maximum acceptable donor height |
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| Donor characteristics |
Maximum acceptable donor height (unit) |
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| Donor characteristics |
Maximum acceptable donor BMI |
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| Donor characteristics |
Acceptable donor birth sex |
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| Donor characteristics |
Additional donor acceptance and/or exclusion criteria to display as information to OPO |
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| Donor clinical data |
Accept VCA - upper limb if procured by another team? |
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| Donor clinical data > Recovery |
Maximum nautical miles the organ or recovery team will travel |
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| Verify ABO |
ABO |
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| HIV Verification |
Is the candidate HIV positive and willing to accept an HIV positive VCA - upper limb? |
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| OMB No. 0915-0157; Expiration Date: XX/XX/20XX |
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| PUBLIC BURDEN STATEMENT: |
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| The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 0.27 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. |