| Ventilated Patient Form |
| Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
Form Logic |
| Hospital and OPO Data |
Status |
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Read-only |
| Hospital and OPO Data |
DonorNet Donor ID |
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| Hospital and OPO Data |
OPO Record ID |
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| Hospital and OPO Data |
OPO |
Cascades from database unless no DonorNet Donor ID |
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| Hospital and OPO Data |
Patient Hospital |
Cascades from database unless no DonorNet Donor ID |
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| Hospital and OPO Data |
Case detail/How did the OPO learn of this patient? |
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| Demographic and Clinical Data |
Last Name |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
First Name |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Middle Initial |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Home Zip Code |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Ethnicity |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Race |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Birth Sex |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Height |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Weight |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Age |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Cause of Death |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Mechanism of Death |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Circumstance of Death |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
Did patient legally document their decision to be an organ donor? |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
First Person Authorization Restrictions |
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Conditional, if Did patient legally document… Yes |
| Demographic and Clinical Data |
Date and Time of Pronouncement of Death |
Cascades from database unless no DonorNet Donor ID |
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| Demographic and Clinical Data |
KDPI |
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| OPO Process Data |
Date of Death Record Review |
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| OPO Process Data |
Was the patient referred by the hospital to the OPO? |
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| OPO Process Data |
Date and Time of Hospital Referral |
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Conditional, if Was the patient referred...Yes |
| OPO Process Data |
OPO Onsite Response |
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Conditional, if Was the patient referred...Yes |
| OPO Process Data |
Date and Time OPO Onsite Response |
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Conditional, if OPO Onsite Response Yes |
| OPO Process Data |
Remote EMR Access |
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| OPO Process Data |
Advance Directive |
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| OPO Process Data |
Patient Record Type |
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| OPO Process Data |
Was the patient medically ruled out by the OPO prior to approach? |
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| OPO Process Data |
Method of Authorization Used by OPO |
Cascades from database unless no DonorNet Donor ID |
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| OPO Process Data |
Family Objection |
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Conditional, if Method of Authorization is First Person Authorization |
| OPO Process Data |
Approaches |
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Conditional, if Method of Authorization is Hierarchy |
| OPO Process Data |
Date and Time of First Approach |
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Conditional, if Method of Authorization is Hierarchy |
| OPO Process Data |
Modality of First Approach |
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Conditional, if Method of Authorization is Hierarchy |
| OPO Process Data |
Language of First Approach |
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Conditional, if Method of Authorization is Hierarchy |
| OPO Process Data |
Interpreter for Approach |
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Conditional, if Method of Authorization is Hierarchy |
| OPO Process Data |
Authorization |
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Conditional, if Method of Authorization is Hierarchy |
| OPO Process Data |
Date and Time Authorization Obtained |
Cascades from database unless no DonorNet Donor ID exists; "Date and Time Consent Obtained for Organ Donation" |
Conditional, if Method of Authorization is Hierarchy |
| OPO Process Data |
Tissue Authorization |
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| Terminal Step |
Case Disposition |
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| Terminal Step/Hospital Interference |
Describe Hospital Interference |
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Conditional, if Case Disposition is Hospital Interference |
| Terminal Step/Hospital Interference |
Report Provided to Hospital |
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Conditional, if Case Disposition is Hospital Interference |
| Terminal Step/Hospital Interference |
Report to Hospital Accepted |
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Conditional, if Case Disposition is Hospital Interference |
| Terminal Step/Hospital Interference |
Remediation Plan Provided to Hospital |
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Conditional, if Case Disposition is Hospital Interference |
| Terminal Step/Hospital Interference |
Remediation Plan for Hospital Accepted |
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Conditional, if Case Disposition is Hospital Interference |
| Terminal Step |
Date and Time Case Close |
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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 0.50 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].
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