1 Deceased Donor Registration_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Deceased Donor Registration_Form.xlsx

Deceased Donor Registration (DDR)

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf



Deceased Donor Registration (DDR)




Fields to be completed by members

















Form Section Field Label Notes




Donor Information Donor ID Display Only - Cascades from feedback




Donor Information OPO Center Code //OPO Display Only - Cascades from feedback




Donor Information OPO Center Type //OPO Display Only - Cascades from feedback




Donor Information Donor Hospital Provider Number Display Only - Cascades from feedback




Donor Information Donor Hospital Name Display Only - Cascades from Database




Donor Information Donor Hospital Display Only - Cascades from Database




Donor Information Referral Date




Donor Information Recovered Outside the U.S.




Donor Information Country




Donor Information Last Name




Donor Information First Name




Donor Information MI Not required




Donor Information DOB




Donor Information Age




Donor Information Age Unit




Donor Information Gender




Donor Information Home City




Donor Information State




Donor Information Zip Code




Donor Information Ethnicity/Race




Donor Information Citizenship




Donor Information Home Country




Donor Information Cause of Death




Donor Information Cause of Death //Specify




Donor Information Mechanism of Death




Donor Information Circumstances of Death




Procurement and Authorization Medical Examiner/Coroner




Procurement and Authorization Was the patient declared legally brain dead?





Procurement and Authorization Did the patient have written documentation of their intent to be a donor




Procurement and Authorization Driver's license




Procurement and Authorization Donor Card




Procurement and Authorization Donor Registry




Procurement and Authorization Durable Power of Attorney / Healthcare Proxy




Procurement and Authorization Advanced Directive





Procurement and Authorization Other Consent Mechanism //Other Specify




Procurement and Authorization Was the consent based solely on this documentation




Procurement and Authorization Did the patient express to family or others the intent to be a donor




Procurement and Authorization Cardiac arrest since neurological event that led to declaration of brain death




Procurement and Authorization Duration of Resuscitation //If Yes, Duration of Resuscitation




Procurement and Authorization Duration of Resuscitation //Status Value or status is reported, not both




Procurement and Authorization Date and time of pronouncement of death: (Complete for brain dead and DCD donors)




Procurement and Authorization Date and time consent obtained for organ donation




Clinical Information ABO Blood Group Display Only - Cascades from feedback




Clinical Information Height in Ft//Height Display Only - Cascades from Database




Clinical Information Height in In//Height Display Only - Cascades from Database




Clinical Information Height in cm




Clinical Information Height in cm //Status Value or status is reported, not both




Clinical Information Weight in Lbs//Weight Display Only - Cascades from Database




Clinical Information Weight in kg




Clinical Information Weight in kg //Status Value or status is reported, not both




Terminal Lab Data Protein in Urine




Terminal Lab Data Serum Sodium




Terminal Lab Data Serum Sodium Status //Status Value or status is reported, not both




Terminal Lab Data BUN




Terminal Lab Data BUN //Status Value or status is reported, not both




Terminal Lab Data Serum Creatinine




Terminal Lab Data Serum Creatinine //Status Value or status is reported, not both




Terminal Lab Data Total Bilirubin




Terminal Lab Data Total Bilirubin //Status Value or status is reported, not both




Terminal Lab Data SGOT/AST




Terminal Lab Data SGOT/AST Status //Status Value or status is reported, not both




Terminal Lab Data SGPT/ALT




Terminal Lab Data SGPT/ALT //Status Value or status is reported, not both




Terminal Lab Data INR




Terminal Lab Data INR //Status Value or status is reported, not both




Terminal Lab Data Hematocrit




Terminal Lab Data Hematocrit //Status Value or status is reported, not both




Terminal Lab Data Serum Amylase




Terminal Lab Data Serum Amylase //Status Value or status is reported, not both




Terminal Lab Data Serum Lipase




Terminal Lab Data Serum Lipase //Status Value or status is reported, not both




Terminal Lab Data HbA1c





Terminal Lab Data HbA1c//Status Value or status is reported, not both




Serology HIV Serology Results




Serology HIV Antigen/Antibody





Serology HTLV Serology Results




Serology RPR-VDRL




Serology Anti-CMV




Serology HBsAg Serology Results




Serology Anti-HBc Serology Results




Serology Anti-HCV Serology Results




Serology HBsAb




Serology EBV (VCA) (lgG)




Serology EBV (VCA) (lgM)




Serology EBNA




Serology Chagas Serology Results





Serology West Nile Serology Results





Serology Toxoplasma (IgG) Results





Serology Strongyloides Results





NAT Results: HIV NAT Results





NAT Results: HBV DNA Results





NAT Results: HCV NAT Results





NAT Results: HTLV NAT Results





NAT Results: Chagas NAT Results





NAT Results: West Nile NAT Results





Donor Management Steroids




Donor Management Diuretics




Donor Management T3




Donor Management T4




Donor Management Antihypertensives




Donor Management Vasodilators




Donor Management DDAVP




Donor Management Heparin




Donor Management Arginine Vasopressin




Donor Management Insulin




Donor Management Donor management other medication, specify Not required




Donor Management Donor management other medication, specify (2) Not required




Donor Management Donor management other medication, specify (3) Not required




Donor Management Inotropic Medications at Time of Cross Clamp




Donor Management Medication




Donor Management Medication //Specify




Donor Management Medication




Donor Management Medication //Specify




Donor Management Medication




Donor Management Medication //Specify




Donor Management Number of transfusions during this (terminal) hospitalization




Clinical Infection Clinical Infection Confirmed by Culture




Clinical Infection Source





Clinical Infection Blood




Clinical Infection Lung




Clinical Infection Urine




Clinical Infection Other




Clinical Infection Other, specify




Lifestyle Factors Cigarette Use (> 20 pack years) - Ever




Lifestyle Factors Cigarette Use //AND continued in last six months




Lifestyle Factors Cocaine Use - Ever




Lifestyle Factors Cocaine Use //AND continued in last six months




Lifestyle Factors Other Drug Use (non - IV) - Ever




Lifestyle Factors Other Drug Use //AND continued in last six months




Lifestyle Factors Heavy Alcohol Use (heavy= 2+ drinks/day)




Lifestyle Factors Tattoos




Lifestyle Factors According to the OPTN policy in effect on the date of referral, does the donor have risk factors for blood-borne disease transmission




Lifestyle Factors History of Diabetes




Lifestyle Factors Insulin Dependent




Lifestyle Factors History of Hypertension




Lifestyle Factors Diet




Lifestyle Factors Diuretics




Lifestyle Factors Other anti-hypertensive medication




Lifestyle Factors History of Cancer




Lifestyle Factors History of Cancer //Specify




Lifestyle Factors Cancer Free Interval




Lifestyle Factors Cancer Free Interval //Status Value or status is reported, not both




Lifestyle Factors Intracranial




Lifestyle Factors Type (Intracranial):





Lifestyle Factors Other Type/ Specify





Lifestyle Factors Extracranial




Lifestyle Factors Type (for Extracranial):





Lifestyle Factors Other Type/ Specify





Lifestyle Factors Skin




Lifestyle Factors Type (for Skin):





Lifestyle Factors Other Type/ Specify





Lifestyle Factors Chagas History





Lifestyle Factors TB History





Organ Recovery Recovery Date (donor to OR)




Organ Recovery Was this donor recovered under DCD protocol




Organ Recovery If Yes, Controlled




Organ Recovery If Yes, Date and time of withdrawal of support




Organ Recovery If Yes, Date and time agonal phase begins (systolic BP < 80 or O2 sat. < 80%)




Organ Recovery If DCD, Total urine output during OR recovery phase




Organ Recovery DCD Measures//Date and time of measures




Organ Recovery DCD Measures//Systolic blood pressure




Organ Recovery DCD Measures//Systolic blood pressure//Status Value or status is reported, not both




Organ Recovery DCD Measures//Diastolic blood pressure




Organ Recovery DCD Measures//Diastolic blood pressure//Status Value or status is reported, not both




Organ Recovery DCD Measures//Mean arterial pressure




Organ Recovery DCD Measures//Mean arterial pressure//Status Value or status is reported, not both




Organ Recovery DCD Measures//O2 saturation




Organ Recovery DCD Measures//O2 saturation//Status Value or status is reported, not both




Organ Recovery If Yes, Core Cooling Used




Organ Recovery If yes, Date and time of abdominal aorta core cooling




Organ Recovery Date and time of abdominal aorta core cooling://Status Value or status is reported, not both




Organ Recovery If yes, Date and time of thoracic aorta core cooling




Organ Recovery Date and time of thoracic aorta core cooling://Status Value or status is reported, not both




Organ Recovery If yes, Date and time of portal vein core cooling




Organ Recovery Date and time of portal vein core cooling://Status Value or status is reported, not both




Organ Recovery If yes, Date and time of pulmonary artery core cooling




Organ Recovery Date and time of pulmonary artery core cooling://Status Value or status is reported, not both




Organ Recovery If No, Was this a consented DCD donor that progressed to brain death?




Organ Recovery Clamp Date




Organ Recovery Clamp Time: (Military Time)




Organ Recovery Clamp Time //Status Value or status is reported, not both




Organ Recovery Clamp Time Zone




Organ Recovery History of previous MI




Organ Recovery LV ejection fraction (%)




Organ Recovery LV Ejection Fraction % //Status Value or status is reported, not both




Organ Recovery Method




Organ Recovery Structural Abnormalities //Valves




Organ Recovery Structural Abnormalities //Congenital




Organ Recovery Structural Abnormalities //LVH




Organ Recovery Wall Abnormalities //Segmental




Organ Recovery Wall Abnormalities //Global




Organ Recovery Heart machine perfusion





Organ Recovery Coronary Angiogram




Organ Recovery If Abnormal, # of Vessels with > 50% Stenosis




Organ Recovery ABG Results Display Only




Organ Recovery Blood pH




Organ Recovery PH //Status Value or status is reported, not both




Organ Recovery PCO<sub>2




Organ Recovery PCO2 //Status Value or status is reported, not both




Organ Recovery PO2





Organ Recovery PO2//Status Value or status is reported, not both




Organ Recovery FiO2





Organ Recovery FiO2//Status Value or status is reported, not both




Organ Recovery PEEP





Organ Recovery PEEP//Status Value or status is reported, not both




Organ Recovery Ventilator Mode





Organ Recovery Ventilator Mode//Other Specify





Organ Recovery Was a pulmonary artery catheter placed




Organ Recovery MAP (initial) // MAP: (mm Hg)




Organ Recovery MAP (initial) //Status Value or status is reported, not both




Organ Recovery MAP (final) // MAP: (mm Hg)




Organ Recovery MAP (final) //Status Value or status is reported, not both




Organ Recovery CVP (initial) // CVP: (mm Hg)




Organ Recovery CVP (initial) //Status Value or status is reported, not both




Organ Recovery CVP (final) // CVP: (mm Hg)




Organ Recovery CVP (final) //Status Value or status is reported, not both




Organ Recovery PCWP (initial) // PCWP: (mm Hg)




Organ Recovery PCWP (initial) //Status Value or status is reported, not both




Organ Recovery PCWP (final) // PCWP: (mm Hg)




Organ Recovery PCWP (final) //Status Value or status is reported, not both




Organ Recovery SVR (initial) //SVR: ((dynes/sec/cm)^5)




Organ Recovery SVR (initial) //Status Value or status is reported, not both




Organ Recovery SVR (final) //SVR




Organ Recovery SVR (final) //Status Value or status is reported, not both




Organ Recovery PA Systolic (initial) // PA Systolic: (mm Hg)




Organ Recovery PA Systolic (initial) //Status Value or status is reported, not both




Organ Recovery PA Systolic (final) // PA Systolic: (mm Hg)




Organ Recovery PA Systolic (final) //Status Value or status is reported, not both




Organ Recovery PA Diastolic (initial) // PA Diastolic: (mm Hg)




Organ Recovery PA Diastolic (initial) //Status Value or status is reported, not both




Organ Recovery PA Diastolic (final) // PA Diastolic: (mm Hg)




Organ Recovery PA Diastolic (final) //Status Value or status is reported, not both




Organ Recovery CO (initial) (L/min) //CO: (L/min)




Organ Recovery CO (initial) //Status Value or status is reported, not both




Organ Recovery CO (final) (L/min) //CO




Organ Recovery CO (final) //Status Value or status is reported, not both




Organ Recovery Cardiac Index (initial) //Cardiac Index: (L/min/sq.m)




Organ Recovery Cardiac Index (initial) //Status Value or status is reported, not both




Organ Recovery Cardiac Index (final) //Cardiac Index




Organ Recovery Cardiac Index (final) //Status Value or status is reported, not both




Organ Recovery Biopsy (heart donors only)




Organ Recovery Other Diagnosis /Specify




Organ Recovery Any Extracorporeal Support Given





Organ Recovery How long:





Organ Recovery How long://Status Value or status is reported, not both




Organ Recovery Flow Rate





Organ Recovery Flow Rate//Status Value or status is reported, not both




Organ Recovery Left Kidney Biopsy




Organ Recovery Type of Biopsy





Organ Recovery Type of Biopsy//Specify





Organ Recovery Interstitial Fibrosis





Organ Recovery Vascular Changes





Organ Recovery Number of Glomeruli Visualized





Organ Recovery % Glomerulosclerosis (Left Kidney) //Glomerulosclerosis




Organ Recovery Pump (Left Kidney) //Pump




Organ Recovery Final Resistance Prior to Shipping (left) //Final Resistance Prior to Shipping




Organ Recovery Final Resistance Prior to Shipping (left) //Status Value or status is reported, not both




Organ Recovery Transferred on pump (left):// Transferred to transplant center on pump




Organ Recovery Type of Left Kidney Pump/Machine





Organ Recovery Type of Left Kidney Pump/Machine//Specify





Organ Recovery Kidney Biopsy (right)://Right Kidney Biopsy




Organ Recovery Type of Biopsy





Organ Recovery Type of Biopsy//Specify





Organ Recovery Interstitial Fibrosis





Organ Recovery Vascular Changes





Organ Recovery Number of Glomeruli Visualized





Organ Recovery % Glomerulosclerosis (Right Kidney)://Glomerulosclerosis




Organ Recovery Pump (Right Kidney) //Pump




Organ Recovery Final Resistance Prior to Shipping (right) //Final Resistance Prior to Shipping




Organ Recovery Final Resistance Prior to Shipping (right) //Status Value or status is reported, not both




Organ Recovery Transferred on pump (right):// Transferred to transplant center on pump




Organ Recovery Type of Right Kidney Pump/Machine





Organ Recovery Type of Right Kidney Pump/Machine//Specify





Organ Recovery Liver Biopsy




Organ Recovery Type of Liver Biopsy





Organ Recovery Type of Liver Biopsy//Specify





Organ Recovery Fibrosis





Organ Recovery Portal Infiltrates





Organ Recovery % Macro vesicular fat




Organ Recovery % Macro vesicular fat //Status Value or status is reported, not both




Organ Recovery % Micro/intermediate vesicular fat




Organ Recovery % Micro/intermediate vesicular fat //Status Value or status is reported, not both




Organ Recovery Liver Machine Perfusion





Organ Recovery Type of Liver Machine Perfusion





Organ Recovery Type of Liver Machine Perfusion//Specify





Organ Recovery Left Lung Bronchoscopy




Organ Recovery Left Lung Machine Perfusion





Organ Recovery Right Lung Bronchoscopy




Organ Recovery Right Lung Machine Perfusion





Organ Recovery Chest X-ray




Organ Disposition Disposition of Organ - Right Kidney://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time right kidney recovered/removed from donor




Organ Disposition Recipient: RKI Display Only - Cascades from Database




Organ Disposition SSN: RKI Display Only - Cascades from Database




Organ Disposition TX Center: RKI Display Only - Cascades from Database




Organ Disposition Reason Code - Right Kidney://Reason Code




Organ Disposition Reason Code Right Kidney //Specify




Organ Disposition Reason organ not transplanted - Right Kidney://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Right Kidney //Specify




Organ Disposition Recovery Team# - Right Kidney://Recovery Team#




Organ Disposition Initial Flush Solution - Right Kidney://Initial Flush Solution




Organ Disposition Initial Flush - Right Kidney //Specify




Organ Disposition Back Table Flush Solution - Right Kidney://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Right Kidney //Specify




Organ Disposition chest X-ray




Organ Disposition Final Flush Right Kidney //Specify




Organ Disposition OPO sent vessels with organ: RKI Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: RKI Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: RKI Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Left Kidney://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time left kidney recovered/removed from donor




Organ Disposition Recipient: LKI Display Only - Cascades from Database




Organ Disposition SSN: LKI Display Only - Cascades from Database




Organ Disposition TX Center: LKI Display Only - Cascades from Database




Organ Disposition Reason Code - Left Kidney://Reason Code




Organ Disposition Reason Code Left Kidney //Specify




Organ Disposition Reason organ not transplanted - Left Kidney://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Left Kidney //Specify




Organ Disposition Recovery Team# - Left Kidney://Recovery Team#




Organ Disposition Initial Flush Solution - Left Kidney://Initial Flush Solution




Organ Disposition Initial Flush - Left Kidney //Specify




Organ Disposition Back Table Flush Solution - Left Kidney://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Left Kidney //Specify




Organ Disposition Final Flush Solution - Left Kidney://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Left Kidney //Specify




Organ Disposition OPO sent vessels with organ: LKI Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: LKI Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: LKI Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Double/En-bloc Kidney://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time double/en-bloc kidney recovered/removed from donor




Organ Disposition Recipient: EKI Display Only - Cascades from Database




Organ Disposition SSN: EKI Display Only - Cascades from Database




Organ Disposition TX Center: EKI Display Only - Cascades from Database




Organ Disposition Reason Code - Double/En-bloc Kidney://Reason Code




Organ Disposition Reason Code - Double/En-bloc Kidney //Specify




Organ Disposition Reason organ not transplanted -Double/En-bloc Kidney://Reason organ not transplanted




Organ Disposition Reason organ not transplanted - Double/En-bloc Kidney //Specify




Organ Disposition Recovery Team# - Double/En-bloc Kidney://Recovery Team#




Organ Disposition Initial Flush Solution - Double/En-bloc Kidney://Initial Flush Solution




Organ Disposition Initial Flush - Double/En-bloc Kidney //Specify




Organ Disposition Back Table Flush Solution - Double/En-bloc Kidney://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Double/En-bloc Kidney //Specify




Organ Disposition Final Flush Solution - Double/En-bloc Kidney://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Double/En-bloc Kidney //Specify




Organ Disposition OPO sent vessels with organ: EKI Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: EKI Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: EKI Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Pancreas://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time whole pancreas recovered/removed from donor




Organ Disposition Recipient: PA Display Only - Cascades from Database




Organ Disposition SSN: PA Display Only - Cascades from Database




Organ Disposition TX Center: PA Display Only - Cascades from Database




Organ Disposition Reason Code - Pancreas://Reason Code




Organ Disposition Reason Code - Pancreas //Specify




Organ Disposition Reason organ not transplanted -Pancreas://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Pancreas //Specify




Organ Disposition Recovery Team# - Pancreas://Recovery Team#




Organ Disposition Initial Flush Solution - Pancreas://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Pancreas //Specify




Organ Disposition Initial Flush Solution Volume





Organ Disposition Initial Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Back Table Flush Solution - Pancreas://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Pancreas //Specify




Organ Disposition Back Table Flush Solution Volume





Organ Disposition Back Table Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Final Flush Solution - Pancreas://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Pancreas //Specify




Organ Disposition OPO sent vessels with organ: PA Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: PA Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: PA Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Pancreas Segment 1://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date, and time pancreas segment 1 recovered/removed from donor




Organ Disposition Recipient: PAS1 Display Only - Cascades from Database




Organ Disposition SSN: PAS1 Display Only - Cascades from Database




Organ Disposition TX Center: PAS1 Display Only - Cascades from Database




Organ Disposition Reason Code - Pancreas Segment 1://Reason Code




Organ Disposition Reason Code/Specify - Pancreas Segment 1 //Specify




Organ Disposition Reason organ not transplanted -Pancreas Segment 1://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Pancreas Segment 1 //Specify




Organ Disposition Recovery Team# - Pancreas Segment 1://Recovery Team#




Organ Disposition Initial Flush Solution - Pancreas Segment 1://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Pancreas Segment 1 //Specify




Organ Disposition Initial Flush Solution Volume





Organ Disposition Initial Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Back Table Flush Solution - Pancreas Segment 1://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Pancreas Segment 1 //Specify




Organ Disposition Back Table Flush Solution Volume





Organ Disposition Back Table Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Final Flush Solution - Pancreas Segment 1://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Pancreas Segment 1 //Specify




Organ Disposition OPO sent vessels with organ: PAS1 Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: PAS1 Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: PAS1 Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Pancreas Segment 2://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time pancreas segment 2 recovered/removed from donor




Organ Disposition Recipient: PAS2 Display Only - Cascades from Database




Organ Disposition SSN: PAS2 Display Only - Cascades from Database




Organ Disposition TX Center: PAS2 Display Only - Cascades from Database




Organ Disposition Reason Code - Pancreas Segment 2://Reason Code




Organ Disposition Reason Code/Specify - Pancreas Segment 2 //Specify




Organ Disposition Reason organ not transplanted -Pancreas Segment 2://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Pancreas Segment 2 //Specify




Organ Disposition Recovery Team# - Pancreas Segment 2://Recovery Team#




Organ Disposition Initial Flush Solution - Pancreas Segment 2://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Pancreas Segment 2 //Specify




Organ Disposition Initial Flush Solution Volume





Organ Disposition Initial Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Back Table Flush Solution - Pancreas Segment 2://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Pancreas Segment 2 //Specify




Organ Disposition Back Table Flush Solution Volume





Organ Disposition Back Table Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Final Flush Solution - Pancreas Segment 2://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Pancreas Segment 2 //Specify




Organ Disposition OPO sent vessels with organ: PAS2 Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: PAS2 Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: PAS2 Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Liver://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time whole liver recovered/removed from donor




Organ Disposition Recipient: LI Display Only - Cascades from Database




Organ Disposition SSN: LI Display Only - Cascades from Database




Organ Disposition TX Center: LI Display Only - Cascades from Database




Organ Disposition Reason Code - Liver://Reason Code




Organ Disposition Reason Code/Specify - Liver //Specify




Organ Disposition Reason organ not transplanted -Liver://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Liver //Specify




Organ Disposition Recovery Team# - Liver://Recovery Team#




Organ Disposition Initial Flush Solution - Liver://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Liver //Specify




Organ Disposition Initial Flush Solution Volume





Organ Disposition Initial Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Back Table Flush Solution - Liver://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Liver //Specify




Organ Disposition Back Table Flush Solution Volume





Organ Disposition Back Table Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Final Flush Solution - Liver://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Liver //Specify




Organ Disposition OPO sent vessels with organ: LI Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: LI Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: LI Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Liver Segment 1://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time liver segment 1 recovered/removed from donor




Organ Disposition Recipient: LIS1 Display Only - Cascades from Database




Organ Disposition SSN: LIS1 Display Only - Cascades from Database




Organ Disposition TX Center: LIS1 Display Only - Cascades from Database




Organ Disposition Reason Code - Liver Segment 1://Reason Code




Organ Disposition Reason Code/Specify - Liver Segment 1 //Specify




Organ Disposition Reason organ not transplanted -Liver Segment 1://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Liver Segment 1 //Specify




Organ Disposition Recovery Team# - Liver Segment 1://Recovery Team#




Organ Disposition Initial Flush Solution - Liver Segment 1://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Liver Segment 1 //Specify




Organ Disposition Initial Flush Solution Volume





Organ Disposition Initial Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Back Table Flush Solution - Liver Segment 1://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Liver Segment 1 //Specify




Organ Disposition Back Table Flush Solution Volume





Organ Disposition Back Table Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Final Flush Solution - Liver Segment 1://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Liver Segment 1 //Specify




Organ Disposition OPO sent vessels with organ: LIS1 Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: LIS1 Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: LIS1 Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Liver Segment 2://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time liver segment 2 recovered/removed from donor




Organ Disposition Recipient: LIS2 Display Only - Cascades from Database




Organ Disposition SSN: LIS2 Display Only - Cascades from Database




Organ Disposition TX Center: LIS2 Display Only - Cascades from Database




Organ Disposition Reason Code - Liver Segment 2://Reason Code




Organ Disposition Reason Code/Specify - Liver Segment 2 //Specify




Organ Disposition Reason organ not transplanted -Liver Segment 2://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Liver Segment 2 //Specify




Organ Disposition Recovery Team# - Liver Segment 2://Recovery Team#




Organ Disposition Initial Flush Solution - Liver Segment 2://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Liver Segment 2 //Specify




Organ Disposition Initial Flush Solution Volume





Organ Disposition Initial Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Back Table Flush Solution - Liver Segment 2://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Liver Segment 2 //Specify




Organ Disposition Initial Flush Solution Volume





Organ Disposition Initial Flush Solution Volume//Status Value or status is reported, not both




Organ Disposition Final Flush Solution - Liver Segment 2://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Liver Segment 2 //Specify




Organ Disposition OPO sent vessels with organ: LIS2 Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: LIS2 Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: LIS2 Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Intestine://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time whole intestine recovered/removed from donor




Organ Disposition Recipient: IN Display Only - Cascades from Database




Organ Disposition SSN: IN Display Only - Cascades from Database




Organ Disposition TX Center: IN Display Only - Cascades from Database




Organ Disposition Reason Code - Intestine://Reason Code




Organ Disposition Reason Code/Specify - Intestine //Specify




Organ Disposition Reason organ not transplanted -Intestine ://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Intestine //Specify




Organ Disposition Recovery Team# - Intestine://Recovery Team#




Organ Disposition Initial Flush Solution - Intestine://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Intestine //Specify




Organ Disposition Back Table Flush Solution - Intestine://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Intestine //Specify




Organ Disposition Final Flush Solution - Intestine://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Intestine //Specify




Organ Disposition OPO sent vessels with organ: IN Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: IN Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: IN Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Intestine Segment 1://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time intestine segment 1 recovered/removed from donor




Organ Disposition Recipient: INS1 Display Only - Cascades from Database




Organ Disposition SSN: INS1 Display Only - Cascades from Database




Organ Disposition TX Center: INS1 Display Only - Cascades from Database




Organ Disposition Reason Code - Intestine Segment 1://Reason Code




Organ Disposition Reason Code/Specify - Intestine Segment 1 //Specify




Organ Disposition Reason organ not transplanted -Intestine Segment 1://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Intestine Segment 1 //Specify




Organ Disposition Recovery Team# - Intestine Segment 1://Recovery Team#




Organ Disposition Initial Flush Solution - Intestine Segment 1://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Intestine Segment 1 //Specify




Organ Disposition Back Table Flush Solution - Intestine Segment 1://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Intestine Segment 1 //Specify




Organ Disposition Final Flush Solution - Intestine Segment 1://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Intestine Segment 1 //Specify




Organ Disposition OPO sent vessels with organ: INS1 Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: INS1 Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: INS1 Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Intestine Segment 2://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time intestine segment 2 recovered/removed from donor




Organ Disposition Recipient: INS2 Display Only - Cascades from Database




Organ Disposition SSN: INS2 Display Only - Cascades from Database




Organ Disposition TX Center: INS2 Display Only - Cascades from Database




Organ Disposition Reason Code - Intestine Segment 2://Reason Code




Organ Disposition Reason Code/Specify - Intestine Segment 2 //Specify




Organ Disposition Reason organ not transplanted -Intestine Segment 2://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Intestine Segment 2 //Specify




Organ Disposition Recovery Team# - Intestine Segment 2://Recovery Team#




Organ Disposition Initial Flush Solution - Intestine Segment 2://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Intestine Segment 2 //Specify




Organ Disposition Back Table Flush Solution - Intestine Segment 2://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Intestine Segment 2 //Specify




Organ Disposition Final Flush Solution - Intestine Segment 2://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Intestine Segment 2 //Specify




Organ Disposition OPO sent vessels with organ: INS2 Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: INS2 Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: INS2 Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Heart://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time heart recovered/removed from donor




Organ Disposition Recipient: HR Display Only - Cascades from Database




Organ Disposition SSN: HR Display Only - Cascades from Database




Organ Disposition TX Center: HR Display Only - Cascades from Database




Organ Disposition Reason Code - Heart://Reason Code




Organ Disposition Reason Code/Specify - Heart //Specify




Organ Disposition Reason organ not transplanted -Heart://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Heart //Specify




Organ Disposition Recovery Team# - Heart://Recovery Team#




Organ Disposition Initial Flush Solution - Heart://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Heart //Specify




Organ Disposition Back Table Flush Solution - Heart://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Heart //Specify




Organ Disposition Final Flush Solution - Heart://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Heart //Specify




Organ Disposition OPO sent vessels with organ: HR Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: HR Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: HR Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Right Lung://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time left lung recovered/removed from donor




Organ Disposition Recipient: LUL Display Only - Cascades from Database




Organ Disposition SSN: LUL Display Only - Cascades from Database




Organ Disposition TX Center: LUL Display Only - Cascades from Database




Organ Disposition Reason Code - Right Lung://Reason Code




Organ Disposition Reason Code/Specify - Right Lung //Specify




Organ Disposition Reason organ not transplanted -Right Lung://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Right Lung //Specify




Organ Disposition Recovery Team# - Right Lung://Recovery Team#




Organ Disposition Initial Flush Solution - Right Lung://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Right Lung //Specify




Organ Disposition Back Table Flush Solution - Right Lung://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Right Lung //Specify




Organ Disposition Final Flush Solution - Right Lung://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Right Lung //Specify




Organ Disposition OPO sent vessels with organ: LUL Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: LUL Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: LUL Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Left Lung://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time right lung recovered/removed from donor




Organ Disposition Recipient: LUR Display Only - Cascades from Database




Organ Disposition SSN: LUR Display Only - Cascades from Database




Organ Disposition TX Center: LUR Display Only - Cascades from Database




Organ Disposition Reason Code - Left Lung://Reason Code




Organ Disposition Reason Code/Specify - Left Lung //Specify




Organ Disposition Reason organ not transplanted -Left Lung://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Left Lung //Specify




Organ Disposition Recovery Team# - Left Lung://Recovery Team#




Organ Disposition Initial Flush Solution - Left Lung://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Left Lung //Specify




Organ Disposition Back Table Flush Solution - Left Lung://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Left Lung //Specify




Organ Disposition Final Flush Solution - Left Lung://Final Flush/Storage Solution




Organ Disposition Final Flush Solution Specify - Left Lung //Specify




Organ Disposition OPO sent vessels with organ: LUR Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: LUR Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: LUR Display Only - Cascades from Database




Organ Disposition Disposition of Organ - Double/En-bloc Lung://Organ Display Only - Cascades from feedback




Organ Disposition If DCD, date and time double/en-bloc lung recovered/removed from donor




Organ Disposition Recipient: DLU Display Only - Cascades from Database




Organ Disposition SSN: DLU Display Only - Cascades from Database




Organ Disposition TX Center: DLU Display Only - Cascades from Database




Organ Disposition Reason Code - Double/En-bloc Lung://Reason Code




Organ Disposition Reason Code/Specify - DoubleEn-bloc Lung //Specify




Organ Disposition Reason organ not transplanted -Double/En-bloc Lung://Reason organ not transplanted




Organ Disposition Reason organ not transplanted Other Specify - Double/En-bloc Lung //Specify




Organ Disposition Recovery Team# - Double/En-bloc Lung://Recovery Team#




Organ Disposition Initial Flush Solution - Double/En-bloc Lung://Initial Flush Solution




Organ Disposition Initial Flush Other Specify - Double/En-bloc Lung //Specify




Organ Disposition Back Table Flush Solution - Double/En-bloc Lung://Back Table Flush Solution




Organ Disposition Back Table Flush Solution Specify - Double/En-bloc Lung //Specify




Organ Disposition Final Flush Solution Specify - Double/En-bloc Lung //Specify




Organ Disposition Final Flush Solution - Double/En-bloc Lung://Final Flush/Storage Solution




Organ Disposition OPO sent vessels with organ: DLU Display Only - Cascades from Database




Organ Disposition Were extra vessels used in the transplant procedure: DLU Display Only - Cascades from Database




Organ Disposition Vessel Donor ID: DLU Display Only - Cascades from Database




























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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 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 0.7 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 Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.




































































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