54 Organ Tracking and Validating_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Organ Tracking and Validating_Form.xlsx

Organ Tracking and Validating System

OMB: 0915-0157

Document [xlsx]
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Organ Tracking and Validating



Fields to be completed by members







Form Section Field Label Notes



Organ Check-In Donor ID



Organ Check-In Organ



Organ Check-In ABO



Organ Check-In Facility Type



Organ Check-In Transplant Center



Organ Check-In Check-In Location



Organ Check-In Received By



Organ Check-In Comments



Organ Check-In Was this the expected Donor ID, organ, and laterality (if applicable)?



Organ Re-ship Donor ID



Organ Re-ship Organ



Organ Re-ship ABO



Organ Re-ship Current Facility Type



Organ Re-ship Reship by User Name



Organ Re-ship Where is the Organ Going?



ABO Verification Document First Anastomosis Time



ABO Verification Document Personnel Attesting to Visual Verification



ABO Verification Document Title of Personnel Attesting to Visual Verification



ABO Verification Document Transplant Surgeon Name



ABO Verification Document Transplant Surgeon Title



ABO Verification Document Licensed Health Professional Name



ABO Verification Document Licensed Health Professional Title





















PUBLIC BURDEN STATEMENT:




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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