REDLINE Ventilated Patient Form OPTN Data Process 0906-NEW 11202025

Form Section
Hospital and OPO Data
Hospital and OPO Data
Hospital and OPO Data
Hospital and OPO Data
Hospital and OPO Data
Hospital and OPO Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
Demographic and Clinical Data
1 Demographic and Clinical Data
OPO Process Data
OPO Process Data
2 OPO Process Data
OPO Process Data
3 OPO Process Data
4 OPO Process Data
5 OPO Process Data
OPO Process Data
6 OPO Process Data

7 OPO Process Data
OPO Process Data
OPO Process Data
OPO Process Data
OPO Process Data
OPO Process Data
OPO Process Data
OPO Process Data
OPO Process Data
14 OPO Process Data
8
9
10
11
12
13

15 OPO Process Data
Terminal Step
16 Terminal Step/Hospital Interference
17 Terminal Step/Hospital Interference
18 Terminal Step/Hospital Interference
Terminal Step/Hospital Interference
Terminal Step/Hospital Interference
Terminal Step/Hospital Interference
19 Terminal Step
OMB No. 0906-XXXX; Expiration Date: XX
PUBLIC BURDEN STATEMENT:
The private, non-profit Organ Procureme
assess whether applicants meet OPTN By
Obligations. An agency may not conduct
OMB control number. The OMB control n
required to obtain or retain a benefit per
0055). Data collected by the private nonmeets or exceeds the requirements as pr
Departments Automated Information Sys
average 0.37 hours per response, includi
information. Send comments regarding t
burden, to HRSA Information Collection C

Field Label

Status
DonorNet Donor ID
OPO Record ID
OPO
Patient Hospital
Case detail/How did the OPO learn of this patient?
Last Name
First Name
Middle Initial
Home Zip Code
Ethnicity
Race
Birth Sex
Height
Weight
Age
Cause of Death
Specify
Mechanism of Death
Circumstance of Death
Did patient legally document their decision to be an
organ donor?
First Person Authorization Restrictions
Date and Time of Pronouncement of Death
KDPI
Was the patient referred by the hospital to the OPO?
Case detail/How did the OPO learn of this patient?
Date of First Hospital Referral for Terminal Admission
Time of First Hospital Referral for Terminal Admission
Date of Death Record Review
OPO Onsite Response
Date and Time First OPO Onsite Response following
Referral
Remote EMR Access
Advance Directive
Patient Record Type Patient Donation Pathway(s)

Was the patient medically ruled out by the OPO prior to
approach?
Method of Authorization Used by OPO
Legal Next of Kin Objection
Approaches
Date and Time of First Approach
Modality of First Approach
Language of First Approach
Interpreter for Approach
Authorization
Date and Time Authorization Obtained for Procurement
Tissue Authorization
Case Disposition
Hospital Interference
Describe Hospital Interference
Report Provided to Hospital Reportable Interference
Report to Hospital Accepted
Remediation Plan Provided to Hospital
Remediation Plan for Hospital Accepted
Date and Time Case Close
X/XX/20XX
ent and Transplantation Network (OPTN) collects this info
ylaw requirements for membership in the OPTN; and to m
or sponsor, and a person is not required to respond to, a
number for this information collection is 0906-XXXX and
r 42 CFR §121.11(b)(2). All data collected will be subject t
-profit OPTN also are well protected by a number of the C
rescribed by OMB Circular A-130, Appendix III, Security of
stems Security Program Handbook. The public reporting
ng the time for reviewing instructions, searching existing
this burden estimate or any other aspect of this collection
Clearance Officer, 5600 Fishers Lane, Room 14NWH04, R

Ventilated Patient Form
Fields to be completed by members
Notes

Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID

Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID
Cascades from database unless no DonorNet Donor ID

Cascades from database unless no DonorNet Donor ID

Cascades from database unless no DonorNet Donor ID exists;
"Date and Time Consent Obtained for Organ Donation"

ormation in order to perform the following OPTN functions: to
monitor compliance of member organizations with OPTN
a collection of information unless it displays a currently valid
it is valid until XX/XX/202X. This information collection is
to Privacy Act protection (Privacy Act System of Records #09-15Contractor’s security features. The Contractor’s security system
f Federal Automated Information Systems, and the
burden for this collection of information is estimated to
g data sources, and completing and reviewing the collection of
n of information, including suggestions for reducing this
ockville, Maryland, 20857 or [email protected].

Read-only

Form Logic

Conditional, if Cause of Death…Other Specify

Conditional, if Did patient legally document… Yes

Conditional, if Case detail/Hospital Referral Was the patient referred...Yes
Conditional, if Case detail/Hospital Referral Was the patient referred...Yes
Conditional, if Case detail/Death Record Review…Yes
Conditional, if Was the patient referred...Yes
Conditional, if OPO Onsite Response... Yes
Conditional, if OPO Onsite Response... No

Conditional, if Was the patient medically ruled out by the OPO... No
Conditional, if Method of Authorization is First Person Authorization
Conditional, if Method of Authorization is Hierarchy
Conditional, if Method of Authorization is Hierarchy Approaches…Yes
Conditional, if Method of Authorization is Hierarchy
Conditional, if Method of Authorization is Hierarchy
Conditional, if Method of Authorization is Hierarchy
Conditional, if Method of Authorization is Hierarchy
Conditional, if Method of Authorization is Hierarchy LNOK Authorized or
Hospital Authorized…selected
Conditional, if Method of Authorization is Hierarchy LNOK Authorized or
Hospital Authorized…selected
Conditionals: if Case detail/date of Death Record Review... Selected; if Was the
patient medically ruled out by the OPO…Yes; Was there an approach for
authorization…No; if LNOK Decline or Hospital Declined…selected
Conditional, if Case Disposition is Hospital Interference is Yes
Conditional, if Case Disposition is Hospital Interference is Yes
Conditional, if Case Disposition is Hospital Interference is Yes
Conditional, if Case Disposition is Hospital Interference is Yes