Potential Transplant Recipient

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

Potential Transplant Recipient

Organ offer responses for potential transplant recipients are entered on matches by either the transplant center or OPOs. This information includes whether the organ was accepted or the offer was refused and the primary reason that the organ offer was refused by the center. Transplant centers evaluate the donor organ information and can respond to the offer at the individual candidate level or enter a response for multiple candidates at once. The OPOs can enter responses to organ offers on behalf of transplant centers.

Match Results

Transplant center contacted?: Indicate if the transplant center was contacted.

Yes, response received

Yes, notified of offer

No, bypassed

Contact last name: If the transplant center was contacted, enter the last name of the person you spoke with at the transplant center. This field is required.

Contact first name: If the transplant center was contacted, enter the first name of the person you spoke with at the transplant center.

Respond date: If the transplant center was contacted, enter the date the transplant center responded to the offer. This field is required.

Respond Time: If the transplant center was contacted, enter the time the transplant center responded to the offer.

Respond time zone: If the transplant center was contacted, the time zone drop-down will be auto-filled with the time zone of the device.

Offer response: Enter the response to the organ offer. If Accept is selected, indicate what organ/segment was placed. If Refuse is selected, enter the refusal codes. This field is required.

Accept

Refuse

Provisional Yes

Primary refusal reason: Select the primary reason for refusal from the dropdown menu. This field is required.

Primary specify: If a code with a “specify” option is selected, enter the information here.

Secondary refusal reason: Select the secondary reason for refusal from the dropdown menu. The secondary refusal code cannot be the same as the primary refusal code.

Secondary specify: If a code with a “specify” option is selected, enter the information here.

If the organ was accepted, complete the following fields, as applicable.

Lung(s) placed:

None

Both

Left

Right

Segment(s) placed: Complete this field for lung only.

None

Both

Left

Right

Heart placed: This field is read-only.

Heart/Lung placed:

Heart

Heart, both lungs

Liver placed:

Whole

Segment

Pancreas placed:

None

Whole

Islet

Kidney placed:

None

Both

Left

Right

Intestine placed:

Whole

Segment

VCA - abdominal wall placed: No selection required.

VCA - external male genitalia placed:

Penis

Scrotum

VCA - head and neck placed:

Face

Larynx

Scalp

Trachea

Vascularized parathyroid gland

Vascularized thyroid

VCA - lower limb(s) placed:

Unilateral: left

Unilateral: right

Bilateral

VCA - musculoskeletal composite graft segment(s) placed:

Chest wall

Spine axis

Composite graft of vascularized muscle, bone, nerve, or skin

VCA - other genitourinary organ placed:

Internal male genitalia

External and internal female genitalia (other than uterus, cervix, and vagina)

Urinary bladder

VCA - spleen placed: No selection required.

VCA - upper limb placed:

Unilateral: left

Unilateral: right

Bilateral

VCA - uterus placed: No selection required.

VCA - vascularized gland(s) placed:

Vascularized adrenal

Vascularized thymus

Verify Organ Offer Info – Update Offer

Primary TXC refusal code: Select the primary reason for refusal from the dropdown menu.

Primary refusal code – specify other: If a code with a “specify” option is selected, enter the information here.

Secondary TXC refusal code: Select the secondary reason for refusal from the dropdown menu. The secondary refusal code cannot be the same as the primary refusal code.

Secondary refusal code – specify other: If a code with a “specify” option is selected, enter the information here.

Primary bypass code: Select the primary bypass reason from the dropdown menu.

Primary bypass specify: If a code with a “specify” option is selected, enter the information here.

Secondary bypass code: Select the secondary bypass reason from the dropdown menu. The secondary bypass reason cannot be the same as the primary bypass reason.

Secondary bypass specify: If a code with a “specify” option is selected, enter the information here.

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