| Living Donor Feedback Form |
| Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
| Institution |
Donor Workup Facility |
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| Donor Information |
Donor last name |
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| Donor Information |
Donor first name |
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| Donor Information |
Donor middle initial |
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| Donor Information |
Donor SSN |
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| Donor Information |
Donor date of birth |
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| Donor Information |
Donor ethnicity |
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| Donor Information |
Donor race |
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| Donor Information |
Donor birth sex |
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| Donor Information |
Donor ABO |
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| Donor Information |
Allow OPO to run match? |
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| Donor Information |
Donor histocompatibility lab |
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| Donor Information |
Living donor recovery procedure aborted after donor received anesthesia OR living donor organ recovered, but not transplanted? |
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| Donor Information |
If yes, was the organ recovered? |
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| Donor Information |
If yes, specify reason procedure was aborted |
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| Donor Information |
Other Specify |
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| Donor Information |
Organ Type |
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| Donor Information |
Is this donor participating in any KPD program |
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| Donor Information |
Social security number of paired candidate |
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| Recipient Information |
Institution |
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| Recipient Information |
Transplant date |
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| Recipient Information |
Recipient last name |
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| Recipient Information |
Recipient first name |
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| Recipient Information |
Recipient middle initial |
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| Recipient Information |
Recipient SSN |
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| Recipient Information |
HIC Number |
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| Recipient Information |
Recipient date of birth |
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| Recipient Information |
Recipient birth sex |
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| Recipient Information |
Recipient ethnicity |
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| Recipient Information |
Recipient race |
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| Recipient Information |
Recipient ABO |
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| Recipient Information |
Were extra vessels used in the transplant procedure |
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| Recipient Information |
Vessel Donor ID |
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| Recipient Information |
Recipient histocompatibility lab |
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| Recipient MELD/PELD |
Test Date |
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| Recipient MELD/PELD |
Serum creatinine |
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| Recipient MELD/PELD |
Had dialysis twice within a week prior to the test? |
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| Recipient MELD/PELD |
Height (cm) |
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| Recipient MELD/PELD |
Date |
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| Recipient MELD/PELD |
Weight (kg) |
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| Recipient MELD/PELD |
Date |
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| Recipient MELD/PELD |
Encephalopathy - Date |
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| Recipient MELD/PELD |
Encephalopathy - Value |
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| Recipient MELD/PELD |
Ascites - Date |
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| Recipient MELD/PELD |
Ascites - Value |
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| Recipient MELD/PELD |
Bilirubin (mg/dl) - Date |
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| Recipient MELD/PELD |
Bilirubin (mg/dl) - Value |
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| Recipient MELD/PELD |
Albumin (g/dl) - Date |
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| Recipient MELD/PELD |
Albumin (g/dl) - Value |
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| Recipient MELD/PELD |
INR - Date |
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| Recipient MELD/PELD |
INR - Value |
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| Recipient MELD/PELD |
Bilirubin (mg/dl) (PBC/PSC/Other Cholestatic) - Date |
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| Recipient MELD/PELD |
Bilirubin (mg/dl) (PBC/PSC/Other Cholestatic) - Value |
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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]. |