Living Donor Feedback Form

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

Living Donor Feedback Form

Living Donor Feedback Form is completed by the living donor work-up facility. All living donors must be registered with UNOS via the living donor feedback form prior to surgery.

Institution

Donor Workup Facility: The donor workup facility will be displayed.

Donor Information

Donor last name: Enter the donor's last name. This is a required field.

Donor first name: Enter the donor's first name. This is a required field.

Donor middle initial: Enter the donor's middle initial, if applicable.

Donor SSN: Enter the donor's social security number using the 9-digit numeric format of ######### or ###-##-####. In the event that no social security number is available (e.g., in the case of a non-U.S. resident), contact the Organ Center at 1-800-292-9537. This is a required field.

Note: SSN cannot:

Contain 00 in the 4th and 5th place (e.g. XXX-00-XXXX is invalid)

Contain 0000 in the last 4 places (e.g. XXX-XX-0000 is invalid)

Begin with 666

Donor date of birth: Enter the donor's date of birth using the 8-digit numeric format of MM/DD/YYYY. This is a required field.

Donor ethnicity: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of ethnicity is aligned to this standard.

OMB defines ethnicity to be whether a person self-identifies as Hispanic origin or not. For this reason, ethnicity is broken out in two categories, (1) Hispanic or Latino or (2) Not Hispanic or Latino. Select one ethnicity category or select ‘Ethnicity Not Reported’ if the donor did not self-identify. This field is required.

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Not Hispanic or Latino

Ethnicity Not Reported

Donor race: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of race is aligned to this standard. OMB defines race as a person’s self-identification with one or more social groups. ​

An individual can select one or more race categories (1) White, (2) Black or African American, (3) Asian, (4) American Indian or Alaska Native, (5) Native Hawaiian or Other Pacific Islander. Select 'Race Not Reported' if the donor’s race is not reported.​ This field is required.​

Note: A person may report multiple races. Persons reporting Hispanic or Latino ethnicity may report themselves as any race category or report no race at all.

Select one or more race sub-categories or origins. Select 'Other Origin' if origin is not listed. Select 'Origin Not Reported' if the origin was not self-identified by the person.​​

White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.​

European Descent​

Arab or Middle Eastern​

North African (non-Black)​

Other Origin​

Origin Not Reported​​

Black or African American – A person having origins in any of the Black racial groups of Africa. ​

African American ​

African (Continental)​

West Indian​

Haitian​

Other Origin​

Origin Not Reported ​​

American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.​

American Indian​

Eskimo​

Aleutian​

Alaska Indian ​

Other Origin​

Origin Not Reported​

Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.​

Asian Indian/Indian Sub-Continent ​

Chinese​

Filipino​

Japanese​

Korean​

Vietnamese​

Other Origin​

Origin Not Reported ​

​Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.​

Native Hawaiian​

Guamanian or Chamorro​

Samoan​

Other Origin​

Origin Not Reported​

Race Not Reported – Select if person did not self-identify a race category or origin.​

Donor birth sex: Report donor sex (Male or Female), based on biologic and physiologic traits at birth. If sex at birth is unknown, report sex at time of donation as reported by donor or documented in medical record. The intent of this data collection field is to capture physiologic characteristics that may have an impact on recipient size matching or graft outcome. This field is required.

Donor ABO: Select the donor's blood type. Note: A2 is used as shorthand for any blood type A subtype other than A1 (i.e., non-A1, negative for A1). A2B is used as shorthand for any blood type AB subtype other than A1B (i.e., non-A1B, negative for A1B). This is a required field. 

O
A
B
AB
A1
A2
A1B
A2B

Note: A second user is required to verify the donor's ABO information. A donor’s blood type cannot be edited after the ABO information has been verified by a second user. However, donors with "A" blood type may be edited only once to a subtype of "A1" or "A2" or "AB" type to "A1B" or "A2B".

Allow OPO to run match? Indicate whether you want to allow the OPO to run a match by selecting Yes or No. Select No if this is a directed donation. If No is selected, complete the expanded Recipient Information section found at the bottom of the page.

Donor histocompatibility lab: Select the histocompatibility lab that typed the donor. If the donor was not typed, select Not Typed. The Not Typed option is not available for kidney, kidney-pancreas and pancreas patients. This is a required field.

Living donor recovery procedure aborted after donor received anesthesia OR living donor organ recovered, but not transplanted?: Indicate whether the transplant procedure was aborted after the donor received anesthesia or if living donor organ was recovered but not transplanted. Not applicable is selected by default for this field. If you need to modify the response, you can change it after adding the living donor. Amend the form or contact the OPTN Contractor to amend the form if the procedure was aborted after the donor received anesthesia OR the living donor organ was recovered but not transplanted into any recipient. Aborted procedures must also be reported via the patient safety portal within 72 hours. This is a required field.

Note: Prior to surgery, select Not applicable. After surgery, choose either Yes or No. If you choose Yes, complete the following fields. A Living Donor Registration (LDR) record will be generated for living donors who have had their procedure aborted.

If yes, was the organ recovered?: Indicate if the organ was recovered by selecting Yes or No.

Note: If an organ was not recovered, a Living Donor Follow-up record (LDF) will not generate.

If yes, specify reason procedure was aborted: If the procedure was aborted after the donor received anesthesia, select the reason. If the reason for aborting the procedure is not listed, select Other Specify and enter the reason in the space provided.

Cardiac Issues

Anesthesia Issues

Donor Anatomy Issues

Recipient Issues

Other Specify

Organ Type: Select the type of organ that was transplanted from the list.

Right Kidney

Left Kidney

Pancreas Segment

Liver Segment

Intestine Segment

Living Donor Heart Transplant

Left Lung Lobe

Right Lung Lobe

Domino Whole Liver

Uterus

Is this donor participating in any KPD program: Select the appropriate response from the drop-down list. This field only displays when Right Kidney or Left Kidney organ is checked and the living donor is added on and after 3/31/2015. This is a required field.

No

Yes, and donor has a paired candidate (The KPD candidate to whom a KPD donor intended to donate the organ before entering into KPD)

Yes, and donor is a non-directed donor (A KPD donor that enters KPD without a paired candidate)

Social security number of paired candidate: If the donor is participating in a KPD program, enter the SSN of their paired candidate (i.e., person to whom they want to donate, but is not compatible with). This is a required field.

Recipient Information

Per OPTN Policy, you must register all patients as candidates on the waiting list BEFORE the transplant program performs the transplant. Remove the candidate from the waiting list with the living donor ID. The recipient's information will show here automatically. However, if the recipient was not registered on the waiting list before transplant, then complete this section AFTER surgery.

Institution: Select the name of the hospital where the recipient's transplant operation was performed. This is a required field. Note: If completing Living Donor Feedback in UNet, the transplant center name will display as the Donor Workup Facility.

Transplant date: Enter the date of the transplant using the 8-digit numeric format of MM/DD/YYYY, or verify that the displayed transplant date is the date of the beginning of the first anastomosis. This is a required field. Verify that the displayed transplant date is correct. The transplant date is determined by the start of the organ anastomosis during transplant or the start of the islet infusion. Organ transplants include solid organ transplants and islet infusions. An organ transplant procedure is complete when any of the following occurs:

• The chest or abdominal cavity is closed and the final skin stitch or staple is applied.

• The transplant recipient leaves the operating room, even if the chest or abdominal cavity cannot be closed.

• The islet infusion is complete

If No was selected for Allow OPO to run match, then the following section must be completed.

Recipient last name: Enter the recipient's last name. This is a required field.

Recipient first name: Enter the recipient's first name. This is a required field.

Recipient middle initial: Enter the recipient's middle initial, if applicable.

Recipient SSN: Enter the recipient's social security number using the 9-digit numeric format of ######### or ###-##-####. This is a required field.

Note: SSN cannot:

Contain 00 in the 4th and 5th place (e.g., XXX-00-XXXX is invalid)

Contain 0000 in the last 4 places (e.g., XXX-XX-0000 is invalid)

Begin with 666

HIC Number: Enter the 9 to 11 character Health Insurance Claim number for the recipient. If the recipient does not have a HIC number, you may leave this field blank.

Recipient date of birth: Enter the recipient's date of birth using the 8-digit numeric format of MM/DD/YYYY. This is a required field.

Recipient birth sex: Indicate whether the recipient's birth sex is Male or Female. This is a required field.

Recipient ethnicity: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of ethnicity is aligned to this standard.

OMB defines ethnicity to be whether a person self-identifies as Hispanic origin or not. For this reason, ethnicity is broken out in two categories, (1) Hispanic or Latino or (2) Not Hispanic or Latino. Select one ethnicity category or select ‘Ethnicity Not Reported’ if the recipient did not self-identify. This field is required.

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Not Hispanic or Latino

Ethnicity Not Reported

Recipient race: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of race is aligned to this standard. OMB defines race as a person’s self-identification with one or more social groups. ​

An individual can select one or more race categories (1) White, (2) Black or African American, (3) Asian, (4) American Indian or Alaska Native, (5) Native Hawaiian or Other Pacific Islander. Select 'Race Not Reported' if the recipient’s race is not reported.​ This field is required.​

Note: A person may report multiple races. Persons reporting Hispanic or Latino ethnicity may report themselves as any race category or report no race at all.

Select one or more race sub-categories or origins. Select 'Other Origin' if origin is not listed. Select 'Origin Not Reported' if the origin was not self-identified by the person.​​

White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.​

European Descent​

Arab or Middle Eastern​

North African (non-Black)​

Other Origin​

Origin Not Reported​​

Black or African American – A person having origins in any of the Black racial groups of Africa. ​

African American ​

African (Continental)​

West Indian​

Haitian​

Other Origin​

Origin Not Reported ​​

American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.​

American Indian​

Eskimo​

Aleutian​

Alaska Indian ​

Other Origin​

Origin Not Reported​

Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.​

Asian Indian/Indian Sub-Continent ​

Chinese​

Filipino​

Japanese​

Korean​

Vietnamese​

Other Origin​

Origin Not Reported ​

​Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.​

Native Hawaiian​

Guamanian or Chamorro​

Samoan​

Other Origin​

Origin Not Reported​

Race Not Reported – Select if person did not self-identify a race category or origin.​

Recipient ABO: Enter the recipient's blood type. This is a required field. 

O
A
B
AB
A1
A2
A1B
A2B

Were extra vessels used in the transplant procedure: Indicate if extra vessels (vascular allografts) were used in the transplant procedure. This is a required field.

Vessel Donor ID: If extra vessels were used in the transplant procedure, enter the Donor ID of the vessel donor. This is a required field.

Note: If the extra vessels used in a transplant procedure are procured from a tissue processing organization, they are not reported in UNet.

Recipient histocompatibility lab: Select the histocompatibility lab that typed the recipient. If the recipient was not typed, select Not Typed. The Not Typed option is not available for kidney, kidney/pancreas, and pancreas patients. This is a required field.

Recipient MELD/PELD

Test Date: Enter the date of the lab tests in the format MM/DD/YYYY. This is a required field.

Serum Creatinine: Enter the serum creatinine value. The value must fall between 0.1 to 20 mg/dL. This field is required for recipients who are 10 and older. If a serum creatinine value is entered, then select Yes or No for Had dialysis twice within a week prior to the test.

Had dialysis twice within a week prior to the test?: If recipient had dialysis twice within a week prior to the serum creatinine test, select Yes. If not, select No. If the recipient did not have a serum creatinine test, select N/A. If the recipient is 10 or older, select Yes or No. This is a required field.

Height: Enter the height of the recipient, at the time of listing, in feet and inches or centimeters. The height must fall between 0 and 7 feet or 1 and 225 centimeters. This is a required field. Enter the Date the recipient's height was measured.

Weight: Enter the weight of the recipient, at the time of listing, in pounds or kilograms. The weight must fall between 0 and 440 pounds or 0 and 200 kilograms. This is a required field. Enter the Date the recipient was weighed.

Child-Turcotte Pugh (CTP) Scoring System to Assess Severity of Liver Disease

Encephalopathy: Enter the date of the encephalopathy test. Then indicate whether the value was None, 1–2, or 3–4. This is a required field. The date is required for all values, except for N/A.

Ascites: Enter the date of the ascites test. Next indicate whether the value was Absent, Slight (or controlled by diuretics) or At least moderate despite diuretic treatment. This is a required field. The date is required for all values, except for N/A.

Bilirubin (mg/dL): Enter the date of the bilirubin test. Next enter the bilirubin value. The normal value is 0.5 - 50 mg/dL. If the value exceeds 50 mg/dL, select OK from the displayed warning message to accept the entered value. If data is entered in this field, do not enter data in the Bilirubin (mg/dl) (PBC/PSC/Other Cholestatic) field.

Albumin (g/dL): Enter the date of the albumin test. Next enter the albumin value. This is a required field.

INR: Enter the date of the INR test. Next enter the INR value. This is a required field.

Bilirubin (mg/dL) (PBC/PSC/Other Cholestatic): Enter the date of the bilirubin (PBC/PSC/Other Cholestatic) test. Next enter the bilirubin value. If the value exceeds 50 mg/dL, select OK from the displayed warning message to accept the entered value. If this field is completed, do not enter data in the Bilirubin field. Only one bilirubin field is required.

Public Burden Statement: 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].   

OPTN Restricted

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