Organ Tracking and Validating System

OMB No. 0915-0157; Expiration Date: XX/XX/202X

Organ Tracking and Validating Form

Enter required data into organ tracking and validating form

A user has the ability to enter donor organ data into the organ tracking and validating system to update a package’s intended destination, document receipt of the package, or create an ABO verification document.

Organ Check-In

Donor ID: OPTN assigned donor identification.

Organ: Organ type

ABO: Donor blood type and subtype.

Facility Type: Facility type that is checking the organ in. This field is required.

Transplant Center

OPO

Transplant Center: Specific transplant center checking organ in. This field is required.

Check-In Location: Specific check-in location of organ at transplant center. This field is required.

Received By: Personnel checking organ in. This field is required.

Comments: Optional comments field.

Was this the expected Donor ID, organ, and laterality (if applicable)?: Question to ensure expected organ was received. This field is required.

Yes

No

Organ Re-ship

Donor ID: OPTN assigned donor identification.

Organ: Organ type

ABO: Donor blood type and subtype.

Current Facility Type: Facility type that is reshipping the organ. This field is required.

Transplant Center

OPO

Reship by User Name: Personnel reshipping organ. This field is required.

Where is the Organ Going?: Intended destination of organ. This field is required.

ABO Verification Document

First Anastomosis Time: Date and Time of the first anastomosis. This field is required.

Personnel Attesting to Visual Verification: Personnel who witnessed the visual verification. This field is required.

Title of Personnel Attesting to Visual Verification: Title of personnel who witnessed the visual verification. This field is required.

Transplant Surgeon Name: Name of transplant surgeon who performed verification. This field is required.

Transplant Surgeon Title: Transplant surgeon title. This field is required.

Licensed Health Professional Name: Name of licensed health professional who performed verification. This field is required.

Licensed Health Professional Title: Licensed health professional title. This field is required.

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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.   

OPTN Restricted

2