Pre-Waitlist Transplant Evaluation Form

OMB No. 0906-XXXX ; Expiration Date: XX/XX/20XX

Pre-Waitlist Transplant Evaluation Form Instructions

OPTN Patient Identification

Transplant Center: The transplant center information displays. Verify that the center information is the hospital where the patient is being evaluated.

Transplant Center Code: The transplant center information displays. Verify that the center information is the hospital where the patient is being evaluated.

Patient MRN: Enter the patient's Medical Record Number at the Transplant Center. This is a required field.

Organ: Select the organ evaluated for transplantation. This is a required field.

Must select one:

Heart

Heart-Lung

Intestine

Kidney

Kidney-Pancreas

Liver

Lung

Pancreas

Pancreas Islets

VCA - abdominal wall

VCA - external male genitalia

VCA - head and neck

VCA - lower limb

VCA - musculoskeletal composite graft segment

VCA - other genitourinary organ

VCA - spleen

VCA - upper limb

VCA - uterus

VCA - vascularized gland

Patient Demographics

First Name: Enter the patient's first name. This is a required field.

Middle Name: Enter the patient's middle name. This is a required field.

Must either:

Provide value,

Select unknown, or

Select not applicable.

Last Name: Enter the patient's last name. This is a required field.

DOB: Enter the patient's date of birth. This is a required field.

Birth Sex: Select the patient's sex (Male or Female), based on biologic and physiologic traits at birth. This is a required field.

Must select one:

Female

Male

SSN: Enter the patient's social security number. This is a required field.

Must either:

Provide value,

Select unknown, or

Select not applicable.

Race: OMB defines race as a person’s self-identification with one or more social groups. This is a required field.

Must select at least one:

White

European Descent

Arab or Middle Eastern

North African (non-Black)

Other Origin

Origin Not Reported

Black or African American

African American

African (Continental)

West Indian

Haitian

Other Origin

Origin Not Reported

Asian

Asian Indian/Indian Sub-Continent

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Origin

Origin Not Reported

American Indian or Alaska Native

American Indian

Eskimo

Aleutian

Alaska Indian

Other Origin

Origin Not Reported

Native Hawaiian or Other Pacific Islander

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Origin

Origin Not Reported

Race Not Reported

Ethnicity: OMB defines ethnicity to be whether or not a person self-identifies as Hispanic or Latino. This is a required field.

Must select one:

Hispanic or Latino,

Not Hispanic or Latino, or

Ethnicity not reported.

Contact Information

Primary Phone Number: Enter the primary phone number at the time of evaluation. This is a required field.

Must either:

Provide value (000-000-0000),

Select unknown, or

Select not applicable.

Permanent Street Address: Enter the street address where the patient permanently resides at the time of evaluation (location of full-time residence, not where the patient is currently staying for the evaluation). This is a required field.

Must either:

Provide value or

Select unknown.

City of Permanent Residence: Enter the city where the patient permanently resides at the time of evaluation (location of full-time residence, not where the patient is currently staying for the evaluation) This is a required field.

Must either:

Provide value or

Select unknown.

State of Permanent Residence: Select the name of the state of the patient's permanent address at the time of evaluation (location of full-time residence, not where the patient is currently staying for the evaluation). This is a required field.

Must either:

Provide value or

Select unknown.

Zip Code of Permanent Residence: Enter the patient's zip code at the time of evaluation (location of full-time residence, not where the patient is currently staying for the evaluation). This is a required field.

Must either:

Provide value or

Select unknown.

Country of Permanent Residence: Enter the country where the patient permanently resides at the time of evaluation (location of full-time residence, not where the patient is currently staying for the evaluation). This is a required field.

Financial Resources

Source of Payment/Primary: Select the patient's primary source of payment (largest contributor) during the evaluation period. This is a required field.

Must select one:

Private insurance (Commercial Health Insurance)

Public insurance – Medicaid

Public insurance – Medicare FFS (Fee-for-Service)

Public insurance – Medicare Part C or Medicare Advantage

Public insurance – CHIP (Children’s Health Insurance Program)

Public insurance – Department of VA

Public insurance – TRICARE

Public insurance – Indian Health Service

Public insurance – State program

Self-pay

Donation

Free Care (Charity Care)

Pending

Foreign Government

Source of Payment/Secondary: Select the patient's secondary source of payment during the evaluation period. This is a required field.

Must select one:

TBD

Working for Income: Required for patients 18 years or older, If the patient is employed (full time or part time) and receiving income at time of evaluation, select Yes. If not currently employed, or is retired, select No. If unknown, select UNK.

Must select one:

Yes – The patient is employed (full time or part time) and receiving income at time of evaluation

No – The patient is not employed or is retired.

Unknown

Patient Measurements

Height: Enter the height of the patient in centimeters at time of evaluation. This is a required field.

Weight: Enter the weight of the patient in kilograms at time of evaluation. This is a required field.

BMI: The patient’s BMI will display.

Evaluation Details

Primary Diagnosis: Select the primary diagnosis for the disease requiring a transplant at the time of evaluation for this candidate. If the candidate has had a previous transplant for the same organ type, use Retransplant/Graft Failure as the primary diagnosis for that organ. This is a required field.

Must either:

Select value (values TBD) or

Select unknown.

Evaluation Status: Select the evaluation status. This is a required field.

Must select one:

Active – The evaluation is in progress.

Closed – The evaluation was closed by the transplant program.

Selection Committee Date: Enter the final selection committee date (MM/DD/YYYY). This is a required field.

Selection Committee Decision: Select the decision value (e.g., approved or denied) from the dropdown menu. This is a required field.

Must select one:

Approved – The selection committee approved adding the patient to the waiting list.

Denied – The selection committee did not approve of adding the patient to the waiting list.

Selection Committee Decision/Declined Reason: Declined reason for transplantation. Select the declined reason from the dropdown menu. This is a required field.

Must select one:

Active infection – Declined due to untreated infection(s) (e.g., HIV, Hepatitis B).

Active mental/behavioral health barriers – Declined due to the presence of untreated or uncontrollable mental health or behavioral health conditions or disorders that interfere with an individual’s ability to make an informed healthcare decision, provide informed consent, or adhere to the established care plan; may also include ongoing behavior that prohibits the delivery of appropriate and adequate transplant-related care, including but not limited to, unwillingness or inability to work productively with the transplant care team.

Active/recent malignancy – Declined due to presence of active malignancy or recent (<5 years) high risk malignancy.

Canceled – Canceled by the transplant program due to erroneous submission.

Financial/insurance issues – Declined due to insufficient finances or insurance coverage for transplant due to a variety of reasons including, but not limited to, immigration status and/or homelessness.

Inadequate patient caregiver support – Declined due to insufficient social support for transplantation and related care.

Nutritional/metabolic issues – Declined due to the presence of significantly low/high BMI measurements, frailty, cachexia, malnutrition and/or poorly controlled metabolic syndrome.

Patient age – Declined due to risks associated with advanced age.

Patient choice – Patient requested to discontinue the transplant referral or evaluation for any reason. This includes transition to hospice.

Patient died – Patient died during course of transplant evaluation.

Patient unable to adhere – Declined due to habitual non-attendance to scheduled appointments and/or nonadherence to the treatment plan.

Refusal to accept blood products – Patient refused to receive blood transfusions due to non-medical reasons.

Refusal to vaccinate – Patient refusing to vaccinate according to present CDC recommendations or programmatic policy for non-medical reasons.

Significant cardiovascular disease – Declined due to the presence of severe cardiovascular disease.

Significant hematologic disease – Declined due to the presence of severe hematologic disease.

Significant hepatic disease – Declined due to the presence of severe hepatic disease.

Significant neuro/cognitive disease – Declined due to the presence of severe neuro/cognitive disease.

Significant pulmonary disease – Declined due to the presence of severe pulmonary disease.

Substance use/abuse – Declined due to reported consumption/misuse of substances either on individual occasions or as a regular practice.

Surgical complexity – Declined due to the presence of significant anatomical issues.

Too well for transplant – Patient's illness is not severe enough for transplant surgery. Transplant program advised the patient to pursue chronic disease management services to prevent progression into end-stage organ failure.

Too sick for transplant – Patient's illness is too severe to undergo transplant surgery (e.g., too unstable, on multiple life support systems, or in a coma with evidence of irreversible brain injury).

Transferred to another center – Patient was transferred to another transplant center.

Transplanted at another center – Patient was transplanted at another transplant center.

Unable to contact patient – Unable to contact the patient due to incomplete or inaccurate information.

Death Date: Required if the Declined Reason is Patient Died, Enter the actual or estimated patient date of death (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 0906-XXXX 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 0.40 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 14NWH04, Rockville, Maryland, 20857 or [email protected].