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Organ Tracking and Validating |
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Fields to be completed by members |
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Form Section |
Field Label |
Notes |
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Organ Check-In |
Donor ID |
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Organ Check-In |
Organ |
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Organ Check-In |
ABO |
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Organ Check-In |
Facility Type |
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Organ Check-In |
Transplant Center |
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Organ Check-In |
Check-In Location |
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Organ Check-In |
Received By |
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Organ Check-In |
Comments |
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Organ Check-In |
Was this the expected Donor ID, organ, and laterality (if applicable)? |
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Organ Re-ship |
Donor ID |
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Organ Re-ship |
Organ |
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Organ Re-ship |
ABO |
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Organ Re-ship |
Current Facility Type |
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Organ Re-ship |
Reship by User Name |
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Organ Re-ship |
Where is the Organ Going? |
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ABO Verification Document |
First Anastomosis Time |
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ABO Verification Document |
Personnel Attesting to Visual Verification |
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ABO Verification Document |
Title of Personnel Attesting to Visual Verification |
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ABO Verification Document |
Transplant Surgeon Name |
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ABO Verification Document |
Transplant Surgeon Title |
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ABO Verification Document |
Licensed Health Professional Name |
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ABO Verification Document |
Licensed Health Professional Title |
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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 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 0.27 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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