Initial Donor Registration
Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
| Details |
Donor Id |
Display only - Calculated |
| Details |
OPO |
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| Details |
Donor hospital |
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| Details |
Time zone |
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| Details |
Is Daylight Savings Time observed? |
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| Details |
Last Name |
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| Details |
First Name |
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| Details |
Middle Initial |
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| Details |
KDPI |
Display only - Calculated |
| Details |
ABO |
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| Details |
Date of birth |
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| Details |
Age (Value) |
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| Details |
Age (Unit) |
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| Details |
Height (ft) |
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| Details |
Height (in) |
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| Details |
Height (cm) |
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| Details |
Weight (lbs) |
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| Details |
Weight (kgs) |
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| Details |
BMI |
Display only - Calculated |
| Details |
Cause of death |
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| Details |
Cause of death - Specify |
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| Details |
Admit date |
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| Details |
time |
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| Details |
Mechanism of injury |
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| Details |
Pronouncement of death date |
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| Details |
time |
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| Details |
Circumstance of death |
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| Details |
Cold ischemic type |
Display only - Calculated |
| Details |
OR Date (status) |
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| Details |
OR Date (date) |
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| Details |
OR Date (time) |
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| Details |
Recovery Facility |
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| Details |
Recovery Facility (Alternate Facility Text) |
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| Details |
Donor meets DCD criteria |
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| Details |
Controlled DCD (status) |
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| Details |
Withdrawal of life-sustaining medical support (date) |
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| Details |
Withdrawal of life-sustaining medical support (time) |
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| Details |
Cessation of circulation, (date) |
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| Details |
Cessation of circulation, (time) |
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| Details |
Normothermic regional perfusion (NRP) (status) |
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| Details |
Initiation of NRP (date) |
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| Details |
Initiation of NRP (time) |
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| Details |
Cardiac arrest / downtime? |
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| Details |
Cardiac arrest / downtime duration (min) |
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| Details |
CPR administered? |
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| Details |
CPR duration (min) |
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| Details |
Ethnicity |
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| Details |
Race |
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| Details |
Was the donor born in a country currently classified as endemic for Chagas disease by the CDC? |
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| Details |
Donor Highlights |
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| Details |
Admission course comments |
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| Details |
History of diabetes |
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| Details |
History of cancer |
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| Details |
History of cancer, specify |
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| Details |
History of hypertension |
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| Details |
Compliant with treatment |
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| Details |
History of coronary artery disease (CAD) |
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| Details |
Previous gastrointestinal disease |
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| Details |
Chest trauma |
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| Details |
Cigarette use (>20 pack years) ever |
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| Details |
And continued in last six months |
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| Details |
Heavy alcohol use (2+ drinks/day) |
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| Details |
I.V. drug usage |
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| Details |
According to the OPTN policy in effect on the date of referral, does the donor have risk factors for blood-borne disease transmission: |
Display only - Calculated |
| Details |
Sex (i.e., any method of sexual contact, including vaginal, anal, and oral) with a person known or suspected to have HIV, HBV, or HCV infection |
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| Details |
Man who has had sex with another man |
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| Details |
Sex in exchange for money or drugs |
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| Details |
Sex with a person who had sex in exchange for money or drugs |
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| Details |
Drug injection for nonmedical reasons |
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| Details |
Sex with a person who injected drugs for nonmedical reasons |
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| Details |
Incarceration (confinement in jail, prison, or juvenile correction facility) for ≥72 consecutive hours |
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| Details |
Child breastfed by a mother with HIV infection |
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| Details |
Child born to a mother with HIV, HBV, or HCV infection |
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| Details |
Unknown medical or social history |
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| Details |
History of myocardial infarction |
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| Details |
Medical and social history comments |
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| Vital Signs |
Begin Date |
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| Vital Signs |
Begin Time |
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| Vital Signs |
End Date |
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| Vital Signs |
End Time |
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| Vital Signs |
Average or Actual BP - Systolic |
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| Vital Signs |
Average or Actual BP - Diastolic |
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| Vital Signs |
Heart Rate - Low (bpm) |
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| Vital Signs |
Heart Rate - High (bpm) |
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| Vital Signs |
High Blood Pressure - Systolic |
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| Vital Signs |
High Blood Pressure - Diastolic |
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| Vital Signs |
Duration at high (minutes) |
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| Vital Signs |
Low Blood Pressure - Systolic |
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| Vital Signs |
Low Blood Pressure - Diastolic |
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| Vital Signs |
Duration at low (minutes) |
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| Vital Signs |
Core Body Temp - Low |
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| Vital Signs |
Core Body Temp - High |
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| Vital Signs |
Core Body Temp - Unit |
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| Vital Signs |
Urine output (cc/hour) - Low |
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| Vital Signs |
Urine output (cc/hour) - High |
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| Vital Signs |
CVP - Low (mm/Hg) |
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| Vital Signs |
CVP - High (mm/Hg) |
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| Vital Signs |
PA Pressure - Systolic - Low (mm/Hg) |
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| Vital Signs |
PA Pressure - Systolic - High (mm/Hg) |
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| Vital Signs |
PA Pressure - Diastolic - Low (mm/Hg) |
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| Vital Signs |
PA Pressure - Diastolic - High (mm/Hg) |
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| Vital Signs |
PCWP - Low (mm/Hg) |
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| Vital Signs |
PCWP - High (mm/Hg) |
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| Vital Signs |
PAMP - Low (mm/Hg) |
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| Vital Signs |
PAMP - High (mm/Hg) |
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| Vital Signs |
Cardiac Output - Low (L/min) |
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| Vital Signs |
Cardiac Output - High (L/min) |
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| Vital Signs |
Cardiac Input - Low (L/min/sq. m) |
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| Vital Signs |
Cardiac Input - High (L/min/sq. m) |
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| Vital Signs |
Date |
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| Vital Signs |
Time |
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| Vital Signs |
Average or Actual BP - Systolic |
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| Vital Signs |
Average or Actual BP - Diastolic |
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| Vital Signs |
Heart Rate (bpm) |
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| Vital Signs |
Core Body Temp (Value) |
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| Vital Signs |
Core Body Temp (Unit) |
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| Vital Signs |
Urine output (cc/hr) |
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| Vital Signs |
CVP (mm/Hg) |
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| Vital Signs |
PA Pressure - Systolic (mm/Hg) |
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| Vital Signs |
PA Pressure - Diastolic (mm/Hg) |
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| Vital Signs |
PCWP (mm/Hg) |
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| Vital Signs |
PAMP (mm/Hg) |
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| Vital Signs |
Cardiac Output (L/min) |
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| Vital Signs |
Cardiac Input (L/min/sq.m) |
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| Vital Signs-DCD Management |
Date |
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| Vital Signs-DCD Management |
Time |
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| Vital Signs-DCD Management |
Average or Actual BP - Systolic |
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| Vital Signs-DCD Management |
Average or Actual BP - Diastolic |
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| Vital Signs-DCD Management |
Heart Rate (bpm) |
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| Vital Signs-DCD Management |
Mean arterial pressure (MAP) |
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| Vital Signs-DCD Management |
Oxygen saturation (SpO2) - (range)
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| Vital Signs |
Vital Signs Comments |
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| Labs |
Date |
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| Labs |
Time |
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| Labs |
WBC (thous/mcL) |
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| Labs |
RBC (mill/mcL) |
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| Labs |
HgB (g/dL) |
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| Labs |
Hct (%) |
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| Labs |
Plt (thous/mcL) |
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| Labs |
Bands (%) |
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| Labs |
Date |
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| Labs |
Time |
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| Labs |
Serum Sodium (mEg/L) |
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| Labs |
K+ (mmol/L) |
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| Labs |
Cl (mmol/L) |
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| Labs |
CO2 (mmol/L) |
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| Labs |
BUN (mg/dL) |
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| Labs |
Creatinine (mg/dL) |
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| Labs |
Glucose (mg/dL) |
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| Labs |
Total Bilirubin (mg/dL) |
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| Labs |
Direct Bilirubin (mg/dL) |
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| Labs |
Indirect Bilirubin (mg/dL) |
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| Labs |
SGOT (AST) (u/L) |
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| Labs |
SGPT (ALT) (u/L) |
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| Labs |
Alkaline phosphatase (u/L) |
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| Labs |
GGT (u/L) |
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| Labs |
LDH (u/L) |
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| Labs |
Albumin (g/dL) |
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| Labs |
Total protein (g/dL) |
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| Labs |
Prothrombin (PT) (seconds) |
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| Labs |
INR |
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| Labs |
PTT (seconds) |
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| Labs |
Serum Amylase (u/L) |
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| Labs |
Serum Lipase (u/L) |
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| Labs |
Serum Lipase Upper Normal Limit (u/L) |
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| Labs |
Date |
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| Labs |
Time |
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| Labs |
Color |
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| Labs |
Appearance |
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| Labs |
pH |
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| Labs |
Specific gravity |
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| Labs |
Protein |
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| Labs |
Protein - Specify |
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| Labs |
Glucose |
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| Labs |
Glucose - Specify |
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| Labs |
Blood |
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| Labs |
Blood - Specify |
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| Labs |
RBC |
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| Labs |
RBC - Specify |
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| Labs |
WBC |
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| Labs |
WBC - Specify |
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| Labs |
Epith (%) |
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| Labs |
Epith (%) - Specify |
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| Labs |
Casts |
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| Labs |
Casts - Specify |
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| Labs |
Bacteria |
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| Labs |
Bacteria - Specify |
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| Labs |
Leukocyte esterase |
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| Labs |
Leukocyte esterase - Specify |
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| Labs |
Date |
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| Labs |
Time |
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| Labs |
pH |
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| Labs |
PaCO2 (mmHg) |
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| Labs |
PaO2 (mmHg) |
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| Labs |
HCO3 (mEq/L) |
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| Labs |
SaO2 (%) |
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| Labs |
Mode |
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| Labs |
Mode - Specify |
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| Labs |
FiO2 (%) |
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| Labs |
RR |
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| Labs |
Vt (cc) |
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| Labs |
PEEP (cmH2O) |
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| Labs |
Date |
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| Labs |
Time |
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| Labs |
CPK (u/L) |
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| Labs |
CK-MB (ng/mL) |
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| Labs |
Troponin I (ng/mL) |
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| Labs |
Troponin T (ng/mL) |
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| Labs |
Toxicology Screen |
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| Labs |
Toxicology Screen - Results |
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| Labs |
HbA1c (%) - Value |
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| Labs |
HbA1c (%) - Date |
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| Labs |
HbA1C (%) - Time |
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| Labs |
Other labs - Specify |
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| Labs |
Date |
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| Labs |
Time |
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| Labs |
Type |
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| Labs |
Type - Specify |
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| Labs |
Result |
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| Labs |
Comments |
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| Meds/Fluids |
Inotropic Medication |
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| Meds/Fluids |
Inotropic Medication - Specify |
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| Meds/Fluids |
Begin Date |
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| Meds/Fluids |
Begin Time |
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| Meds/Fluids |
End Date |
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| Meds/Fluids |
End Time |
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| Meds/Fluids |
Value |
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| Meds/Fluids |
Units |
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| Meds/Fluids |
I.V. fluids (cc/hour) |
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| Meds/Fluids |
Is there dextrose in I.V. fluids? |
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| Meds/Fluids |
Steroids |
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| Meds/Fluids |
Steroids - Specify |
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| Meds/Fluids |
Diuretics |
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| Meds/Fluids |
Diuretics - Specify |
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| Meds/Fluids |
T3 |
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| Meds/Fluids |
T4 |
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| Meds/Fluids |
Insulin |
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| Meds/Fluids |
Insulin - Begin Date |
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| Meds/Fluids |
Insulin - Begin Time |
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| Meds/Fluids |
Insulin - End Date |
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| Meds/Fluids |
Insulin - End Time |
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| Meds/Fluids |
Antihypertensives |
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| Meds/Fluids |
Vasodilators |
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| Meds/Fluids |
Vasodilators - Begin Date |
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| Meds/Fluids |
Vasodilators - Begin Time |
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| Meds/Fluids |
Vasodilators - End Date |
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| Meds/Fluids |
Vasodilators - End Time |
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| Meds/Fluids |
DDAVP |
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| Meds/Fluids |
Arginine vasopressin |
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| Meds/Fluids |
Arginine vasopressin - Begin Date |
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| Meds/Fluids |
Arginine vasopressin - Begin Time |
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| Meds/Fluids |
Arginine vasopressin - End Date |
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| Meds/Fluids |
Arginine vasopressin - End Time |
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| Meds/Fluids |
Total Parenteral Nutrition |
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| Meds/Fluids |
Heparin |
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| Meds/Fluids |
Heparin - Begin Date |
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| Meds/Fluids |
Heparin - Begin Time |
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| Meds/Fluids |
Heparin - End Date |
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| Meds/Fluids |
Heparin - End Time |
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| Meds/Fluids |
Heparin - Units |
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| Meds/Fluids |
Other/specify 1 |
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| Meds/Fluids |
Other/specify 2 |
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| Meds/Fluids |
Other/specify 3 |
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| Meds/Fluids |
Transfusions prior to ABO determination |
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| Meds/Fluids |
Total number |
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| Meds/Fluids |
Total volume |
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| Meds/Fluids |
Transfusions following ABO determination |
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| Meds/Fluids |
Total number |
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| Meds/Fluids |
Total volume |
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| Meds/Fluids |
Other blood products |
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| Meds/Fluids |
Other blood products - Specify |
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| Infectious Diseases |
Anti-HBc |
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| Infectious Diseases |
Anti-HBc - Hemodilution |
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| Infectious Diseases |
HBV NAT |
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| Infectious Diseases |
HBV NAT - Hemodilution |
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| Infectious Diseases |
HBsAg |
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| Infectious Diseases |
HBsAg - Hemodilution |
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| Infectious Diseases |
HBsAb |
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| Infectious Diseases |
HBsAb - Hemodilution |
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| Infectious Diseases |
Anti-HCV |
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| Infectious Diseases |
Anti-HCV - Hemodilution |
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| Infectious Diseases |
HCV NAT |
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| Infectious Diseases |
HCV NAT - Hemodilution |
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| Infectious Diseases |
Anti-HIV I/II |
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| Infectious Diseases |
Anti-HIV I/II - Hemodilution |
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| Infectious Diseases |
HIV Ag/Ab Combo |
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| Infectious Diseases |
HIV Ag/Ab Combo - Hemodilution |
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| Infectious Diseases |
HIV NAT |
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| Infectious Diseases |
HIV NAT - Hemodilution |
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| Infectious Diseases |
Anti-HTLV I/II |
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| Infectious Diseases |
Anti-HTLV I/II - Hemodilution |
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| Infectious Diseases |
HTLV NAT |
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| Infectious Diseases |
HTLV NAT - Hemodilution |
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| Infectious Diseases |
Anti-CMV |
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| Infectious Diseases |
Anti-CMV - Hemodilution |
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| Infectious Diseases |
Syphilis |
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| Infectious Diseases |
Syphilis - Hemodilution |
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| Infectious Diseases |
EBV (VCA) (IgG) |
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| Infectious Diseases |
EBV (VCA) (IgG) - Hemodilution |
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| Infectious Diseases |
EBV (VCA) (IgM) |
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| Infectious Diseases |
EBV (VCA) (IgM) - Hemodilution |
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| Infectious Diseases |
EBNA |
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| Infectious Diseases |
EBNA - Hemodilution |
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| Infectious Diseases |
Toxoplasma (IgG) |
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| Infectious Diseases |
Toxoplasma (IgG) - Hemodilution |
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| Infectious Diseases |
T. cruzi Ab Screen |
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| Infectious Diseases |
T. cruzi Ab Screen - Hemodilution |
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| Infectious Diseases |
West Nile |
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| Infectious Diseases |
West Nile - Hemodilution |
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| Infectious Diseases |
West Nile NAT |
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| Infectious Diseases |
West Nile NAT - Hemodilution |
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| Infectious Diseases |
Strongyloides Ab |
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| Infectious Diseases |
Strongyloides Ab - Hemodilution |
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| Infectious Diseases |
Was COVID-19 (SARS-CoV-2) testing performed on the donor? |
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| Infectious Diseases |
Specimen Date |
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| Infectious Diseases |
Specimen Time |
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| Infectious Diseases |
Specimen Type |
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| Infectious Diseases |
Specimen Type - Specify |
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| Infectious Diseases |
Hemodiluted Specimen |
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| Infectious Diseases |
Test Method |
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| Infectious Diseases |
Test Method - Specify |
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| Infectious Diseases |
Result |
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| Infectious Diseases |
Comments |
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| Infectious Diseases |
Was T. cruzi (Chagas) Ab diagnostic testing performed on the donor? |
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| Infectious Diseases |
Specimen Date |
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| Infectious Diseases |
Specimen Time |
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| Infectious Diseases |
Specimen Type |
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| Infectious Diseases |
Hemodiluted Specimen |
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| Infectious Diseases |
Test Method |
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| Infectious Diseases |
Test Method - Specify |
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| Infectious Diseases |
Result |
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| Infectious Diseases |
Comments |
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| Tests |
Test Type |
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| Tests |
Test Type - Specify |
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| Tests |
Test Date |
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| Tests |
Test Time |
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| Tests |
Diagnostic evaluation/comments |
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| Tests |
Attach medical image |
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| Tests |
Attachment Description |
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| Tests |
Attachment File |
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| Tests |
Study |
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| Attachments |
Attachment Description |
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| Attachments |
Attachment File |
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| Attachments |
Attachment Category |
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| Crossmatch & HLA |
A1 |
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| Crossmatch & HLA |
A2 |
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| Crossmatch & HLA |
B1 |
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| Crossmatch & HLA |
B2 |
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| Crossmatch & HLA |
BW4 |
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| Crossmatch & HLA |
BW6 |
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| Crossmatch & HLA |
C1 |
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| Crossmatch & HLA |
C2 |
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| Crossmatch & HLA |
DR1 |
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| Crossmatch & HLA |
DR2 |
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| Crossmatch & HLA |
DR51 |
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| Crossmatch & HLA |
DR51_2 |
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| Crossmatch & HLA |
DR52 |
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| Crossmatch & HLA |
DR52_2 |
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| Crossmatch & HLA |
DR53 |
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| Crossmatch & HLA |
DR53_2 |
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| Crossmatch & HLA |
DQB1 |
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| Crossmatch & HLA |
DQB1_2 |
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| Crossmatch & HLA |
DQA1 |
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| Crossmatch & HLA |
DQA1_2 |
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| Crossmatch & HLA |
DPB1 |
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| Crossmatch & HLA |
DPB1_2 |
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| Crossmatch & HLA |
DPA1 |
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| Crossmatch & HLA |
DPA1_2 |
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| Crossmatch & HLA |
Is there time for a preliminary crossmatch |
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| Organ Data |
Warm ischemic time (minutes) |
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| Organ Data |
Core cooling flush used |
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| Organ Data |
Abdominal aorta flush time (in situ), (date) |
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| Organ Data |
Abdominal aorta flush time (in situ), (time) |
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| Organ Data |
Portal vein flush time (in situ), (date) |
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| Organ Data |
Portal vein flush time (in situ), (time) |
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| Organ Data |
Thoracic aorta flush time (in situ), (date) |
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| Organ Data |
Thoracic aorta flush time (in situ), (time) |
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| Organ Data |
Pulmonary artery flush time (in situ), (date) |
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| Organ Data |
Pulmonary artery flush time (in situ), (time) |
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| Organ Data |
Left kidney biopsy |
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| Organ Data |
% Global glomerulosclerosis |
Read only - calculated |
| Organ Data |
Biopsy type |
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| Organ Data |
Number of glomeruli |
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| Organ Data |
Pump Date |
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| Organ Data |
Pump Time |
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| Organ Data |
Flow (cc/min) |
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| Organ Data |
Pressure (mmHg) - Systolic |
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| Organ Data |
Pressure (mmHg) - Diastolic |
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| Organ Data |
Resistance |
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| Organ Data |
Left kidney pump device |
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| Organ Data |
Left kidney pump device - Specify |
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| Organ Data |
Left kidney pump solution |
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| Organ Data |
Left kidney pump solution - Specify |
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| Organ Data |
Left kidney tissue preparation technique |
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| Organ Data |
Left kidney number of globally sclerotic glomeruli |
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| Organ Data |
Left kidney nodular mesangial glomerulosclerosis |
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| Organ Data |
Left kidney interstitial fibrosis/tubular atrophy (IFTA) |
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| Organ Data |
Left kidney vascular disease (% luminal narrowing) |
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| Organ Data |
Left kidney arteriolar hyalinosis |
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| Organ Data |
Left kidney cortical Necrosis |
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| Organ Data |
Left kidney % Cortical Necrosis |
|
| Organ Data |
Left kidney Fibrin thrombi |
|
| Organ Data |
Left kidney % Fibrin thrombi |
|
| Organ Data |
Left kidney comments |
|
| Organ Data |
Right kidney biopsy |
|
| Organ Data |
% Global glomerulosclerosis |
Read only - calculated |
| Organ Data |
Biopsy type |
|
| Organ Data |
Number of glomeruli |
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| Organ Data |
Pump Date |
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| Organ Data |
Pump Time |
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| Organ Data |
Flow (cc/min) |
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| Organ Data |
Pressure (mmHg) - Systolic |
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| Organ Data |
Pressure (mmHg) - Diastolic |
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| Organ Data |
Resistance |
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| Organ Data |
Right kidney pump device |
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| Organ Data |
Right kidney pump device - Specify |
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| Organ Data |
Right kidney pump solution |
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| Organ Data |
Right kidney pump solution - Specify |
|
| Organ Data |
Right kidney tissue preparation technique |
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| Organ Data |
Right kidney number of globally sclerotic glomeruli |
|
| Organ Data |
Right kidney nodular mesangial glomerulosclerosis |
|
| Organ Data |
Right kidney interstitial fibrosis/tubular atrophy (IFTA) |
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| Organ Data |
Right kidney vascular disease (% luminal narrowing) |
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| Organ Data |
Right kidney arteriolar hyalinosis |
|
| Organ Data |
Right kidney cortical Necrosis |
|
| Organ Data |
Right kidney % Cortical Necrosis |
|
| Organ Data |
Right kidney Fibrin thrombi |
|
| Organ Data |
Right kidney % Fibrin thrombi |
|
| Organ Data |
Right kidney comments |
|
| Organ Data |
Pancreas comments |
|
| Organ Data |
Liver Biopsy |
|
| Organ Data |
Macrosteatosis % |
|
| Organ Data |
Liver Biopsy comments |
|
| Organ Data |
Liver Comments |
|
| Organ Data |
Intestine comments |
|
| Organ Data |
LV ejection fraction (%) |
|
| Organ Data |
Method |
|
| Organ Data |
Shortening fraction (SF) (%) |
|
| Organ Data |
Septal wall thickness (cm) |
|
| Organ Data |
LV posterior wall thickness (cm) |
|
| Organ Data |
Heart comments |
|
| Organ Data |
Date intubated |
|
| Organ Data |
Time intubated |
|
| Organ Data |
Length of left lung (cm) |
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| Organ Data |
Length of right lung (cm) |
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| Organ Data |
Aortic knob width (cm) |
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| Organ Data |
Diaphragm width (cm) |
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| Organ Data |
Chest circ./landmark (cm) |
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| Organ Data |
Dist. RCPA to LCPA (cm) |
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| Organ Data |
Chest X-ray |
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| Organ Data |
Left lung comments |
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| Organ Data |
Right lung comments |
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| Organ Data |
VCA organs comments |
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| Verify ABO |
ABO |
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| Verify ABO Subtype |
ABO |
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| OMB No. 0915-0157; Expiration Date: XX/XX/20XX |
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| 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. |