| Pre-Waitlist Transplant Evaluation Form |
| Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
| OPTN Patient Identification |
Transplant Center |
Read only |
| OPTN Patient Identification |
Transplant Center Code |
Read only |
| OPTN Patient Identification |
Patient MRN |
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| OPTN Patient Identification |
Organ |
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| Patient Demographics |
First Name |
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| Patient Demographics |
Middle Name |
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| Patient Demographics |
Last Name |
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| Patient Demographics |
DOB |
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| Patient Demographics |
Birth Sex |
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| Patient Demographics |
SSN |
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| Patient Demographics |
Race |
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| Patient Demographics |
Ethnicity |
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| Contact Information |
Primary Phone Number |
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| Contact Information |
Permanent Street Address |
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| Contact Information |
City of Permanent Residence |
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| Contact Information |
State of Permanent Residence |
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| Contact Information |
Zip Code of Permanent Residence |
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| Contact Information |
Country of Permanent Residence |
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| Financial Resources |
Source of Payment/Primary |
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| Financial Resources |
Source of Payment/Secondary |
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| Financial Resources |
Working for Income |
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| Patient Measurements |
Height |
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| Patient Measurements |
Weight |
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| Patient Measurements |
BMI |
Read only |
| Evaluation Details |
Primary Diagnosis |
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| Evaluation Details |
Evaluation Status |
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| Evaluation Details |
Selection Committee Date |
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| Evaluation Details |
Selection Committee Decision |
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| Evaluation Details |
Selection Committee Decision/Declined Reason |
Conditional, if Selection Committee Decision is Denied |
| Evaluation Details |
Selection Committee Decision/Death Date |
Conditional, if Declined Reason is Patient Died |
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| OMB No. 0906-XXXX ; 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 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]. |