Interim Event Reporting Form

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

Interim Event Reporting Form

Interim Report

Name: The recipient's last and first names display.

SSN: The recipient's social security number displays.

Transplant center: The center name and provider number for the center following the recipient displays.

Last seen date: The date that the recipient was last seen, as reported on the last completed TRF, displays.

Patient status: Select the recipient's status from the drop-down list.

Alive
Dead
Retransplanted
Lost to Follow-up

Patient status date:  Enter the date the recipient's status was reported using the standard 8-digit format of MM/DD/YYYY. If the patient is lost to follow-up, enter the day after the recipient was last seen.

Graft status: If Dead or Retransplanted is selected for Patient Status, select the recipient's graft status, at the time of death or retransplant, from the drop-down list. If Alive is selected, select Failed from the drop-down list. If Lost to Follow-up is selected, do not make a selection.

Functioning
Failed

Graft Failure date: If the recipient's graft status is Failed, enter the date of failure using the standard 8-digit format of MM/DD/YYYY.

Note: An interim record can be completed for kidney/pancreas recipients only if the recipient dies or experiences graft failure of BOTH the kidney and pancreas between follow-up intervals. However, if the recipient experiences graft failure of only one organ, then the graft failure must be reported on the next expected KPF record. It may also be reported on the last completed record for the failed organ if it occurred within 2 months of the record completion date.

If reporting graft failure on a kidney/pancreas recipient, Graft Failure date fields will display for both the kidney and pancreas. If graft failure has previously been reported on their record for one of the organs, the graft failure date for that organ will display.

Graft Failure date (KI): Enter the date of failure using the standard 8-digit format of MM/DD/YYYY.

Graft Failure date (PA): Enter the date of failure using the standard 8-digit format of MM/DD/YYYY.

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].

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