| Pediatric Liver Candidate Listing Registration |
| Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
| Add new candidate registration |
Center |
Display Only - Cascades from database |
| Add new candidate registration |
Organ |
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| Candidate Add |
Center |
Display Only - Cascades from database |
| Candidate Add |
Organ |
Display Only - Cascades from database |
| Candidate Add |
SSN |
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| Candidate Add |
Confirm SSN |
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| Candidate Add |
Age Group |
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| Provider Information |
Transplant Hospital |
Display Only - Cascades from database |
| Provider Information |
24 Hour Contact Phone Number |
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| Demographic Information |
SSN |
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| Demographic Information |
Confirm SSN |
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| Demographic Information |
Last Name |
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| Demographic Information |
First Name |
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| Demographic Information |
MI |
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| Demographic Information |
DOB |
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| Demographic Information |
Birth sex |
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| Demographic Information |
Center Patient ID |
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| Demographic Information |
State of Permanent Residence |
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| Demographic Information |
Permanent ZIP Code |
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| Demographic Information |
Ethnicity |
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| Demographic Information |
Race |
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| Clinical Information |
ABO |
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| Clinical Information |
Accept an Incompatible Blood Type? |
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| Clinical Information |
Accept an A2 donor? |
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| Clinical Information |
Height (ft) |
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| Clinical Information |
Height (in) |
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| Clinical Information |
Height (cm) |
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| Clinical Information |
Height Measurement Date |
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| Clinical Information |
Weight (lbs) |
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| Clinical Information |
Weight (kg) |
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| Clinical Information |
Weight Measurement Date |
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| HLA CLASS I |
A |
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| HLA CLASS I |
A |
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| HLA CLASS I |
B |
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| HLA CLASS I |
B |
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| HLA CLASS I |
BW4 |
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| HLA CLASS I |
BW6 |
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| HLA CLASS I |
C |
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| HLA CLASS I |
C |
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| HLA CLASS II |
DR |
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| HLA CLASS II |
DR |
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| HLA CLASS II |
DR51 |
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| HLA CLASS II |
DR51 |
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| HLA CLASS II |
DR52 |
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| HLA CLASS II |
DR52 |
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| HLA CLASS II |
DR53 |
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| HLA CLASS II |
DR53 |
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| HLA CLASS II |
DQB1 |
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| HLA CLASS II |
DQB1 |
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| HLA CLASS II |
DQA1 |
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| HLA CLASS II |
DQA1 |
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| HLA CLASS II |
DPB1 |
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| HLA CLASS II |
DPB1 |
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| HLA CLASS II |
DPA1 |
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| HLA CLASS II |
DPA1 |
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| Organ Information |
Candidate Medical Urgency Status |
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| Organ Information |
Inactive Reason |
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| Organ Information |
Accept a liver for other methods of hepatic support? |
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| Organ Information |
Accept a Segmental Liver? |
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| Organ Information |
Preliminary Crossmatch Required |
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| Organ Information |
Number of previous Liver Transplants |
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| Status 1A Criteria |
Status |
Display Only |
| Status 1A Criteria |
Surgeon/Physician NPI |
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| Status 1A Criteria |
Surgeon/Physician Name |
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| Status 1A Criteria |
Hospital Telephone Number |
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| Status 1A Criteria |
Application Submitted By |
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| Status 1A Criteria |
Email to Notify of RRB Decision |
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| Status 1A Criteria |
Fulminant liver failure? |
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| Status 1A Criteria |
Primary non-function of a transplanted liver? |
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| Status 1A Criteria |
Within how many days of transplantation |
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| Status 1A Criteria |
Transplant Date |
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| Status 1A Criteria |
Draw Date |
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| Status 1A Criteria |
ALT value |
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| Status 1A Criteria |
Arterial pH value |
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| Status 1A Criteria |
Venous pH value |
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| Status 1A Criteria |
Lactate value |
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| Status 1A Criteria |
Hepatic artery thrombosis (HAT) in a transplanted liver? |
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| Status 1A Criteria |
Within how many days of transplantation |
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| Status 1A Criteria |
Transplant Date |
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| Status 1A Criteria |
Acute decompensated Wilson's disease? |
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| Status 1A Criteria |
Clinical Narrative |
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| Status 1A Criteria |
Diagnosis |
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| Status 1B Criteria |
Status |
Display Only |
| Status 1B Criteria |
Surgeon/Physician NPI |
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| Status 1B Criteria |
Surgeon/Physician Name |
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| Status 1B Criteria |
Hospital Telephone Number |
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| Status 1B Criteria |
Application Submitted By |
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| Status 1B Criteria |
Email to Notify of RRB Decision |
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| Status 1B Criteria |
Chronic liver disease |
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| Status 1B Criteria |
Gastrointestinal bleeding requiring red blood cell replacement - Indicate amount |
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| Status 1B Criteria |
Gastrointestinal bleeding requiring red blood cell replacement - Date |
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| Status 1B Criteria |
Non-Metastatic Hepatoblastoma suitable for liver transplantation? |
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| Status 1B Criteria |
Biopsy |
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| Status 1B Criteria |
Date |
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| Status 1B Criteria |
Metabolic disease? |
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| Status 1B Criteria |
Other - Specify |
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| Status 1B Criteria |
Please specify type |
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| Status 1B Criteria |
Diagnosis |
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| MELD/PELD Data Collection |
Serum Creatinine Value |
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| MELD/PELD Data Collection |
Serum Creatinine Date |
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| MELD/PELD Data Collection |
Had dialysis twice, or 24 hours of CVVHD, within a week prior to the serum creatinine test? |
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| MELD/PELD Data Collection |
Serum Sodium Value |
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| MELD/PELD Data Collection |
Serum Sodium Date |
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| MELD/PELD Data Collection |
Encephalopathy Date |
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| MELD/PELD Data Collection |
Encephalopathy - Value |
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| MELD/PELD Data Collection |
Ascites Date |
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| MELD/PELD Data Collection |
Ascites - Value |
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| MELD/PELD Data Collection |
Bilirubin - Date |
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| MELD/PELD Data Collection |
Bilirubin - Value |
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| MELD/PELD Data Collection |
Albumin - Date |
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| MELD/PELD Data Collection |
Albumin - Value |
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| MELD/PELD Data Collection |
INR Date |
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| MELD/PELD Data Collection |
INR - Value |
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| Additional Organs |
Check any additional organs the candidate may need |
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| SLK Registrations |
Chronic Kidney Disease (CKD) |
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| SLK Registrations |
Date |
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| SLK Registrations |
Begun dialysis? |
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| SLK Registrations |
CrCl (measured or estimated) (mL/min) |
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| SLK Registrations |
GFR (measured or estimated) (mL/min) |
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| SLK Registrations |
Sustained acute kidney injury |
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| SLK Registrations |
Date |
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| SLK Registrations |
Begun dialysis? |
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| SLK Registrations |
CrCl (measured or estimated) (mL/min) |
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| SLK Registrations |
GFR (measured or estimated) (mL/min) |
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| SLK Registrations |
Metabolic disease |
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| SLK Registrations |
Transplant nephrologist confirming candidate's most recent diagnosis for SLK |
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| Donor Characteristics |
Acceptable donor age range |
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| Unacceptable Antigens |
A |
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| Unacceptable Antigens |
B |
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| Unacceptable Antigens |
BW |
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| Unacceptable Antigens |
C |
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| Unacceptable Antigens |
DR |
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| Unacceptable Antigens |
DR51 |
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| Unacceptable Antigens |
DR52 |
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| Unacceptable Antigens |
DR53 |
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| Unacceptable Antigens |
DQB1 |
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| Unacceptable Antigens |
DQA1 |
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| Unacceptable Antigens |
DPB1 - Antigens |
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| Unacceptable Antigens |
DPB1 - Epitopes |
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| Unacceptable Antigens |
DPA1 |
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| Verify ABO |
ABO |
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| HIV Verification |
Is the candidate HIV positive and willing to accept an HIV positive heart? |
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| Donor Characteristics |
Local minimum acceptable donor age |
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| Donor Characteristics |
Import minimum acceptable donor age |
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| Donor Characteristics |
Local maximum acceptable donor age |
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| Donor Characteristics |
Import maximum acceptable donor age |
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| Donor Characteristics |
Minimum acceptable donor weight |
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| Donor Characteristics |
Maximum acceptable donor weight |
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| Donor Characteristics |
Maximum acceptable donor BMI |
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| Donor Characteristics |
Local Accept DCD donor? |
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| Donor Characteristics |
Import Accept DCD donor? |
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| Infectious diseases |
Accept a Hepatitis B core antibody positive donor? |
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| Infectious diseases |
Accept an HBV NAT positive donor? |
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| Infectious diseases |
Accept an HCV antibody positive donor? |
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| Infectious diseases |
Accept an HCV NAT positive donor? |
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| HOPE Act IRB research |
Is the candidate HIV positive and willing to accept an HIV positive Liver? |
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| Recovery |
Maximum acceptable cold ischemic time |
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| Recovery |
Maximum miles the organ or recovery team will travel |
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| Lab Values |
Maximum acceptable donor sodium (Na) - peak |
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| Lab Values |
Maximum acceptable donor SGOT (AST) - peak |
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| Lab Values |
Maximum acceptable donor SGPT (ALT) - peak |
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| Lab Values |
Maximum acceptable donor INR - peak |
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| Expedited Donor Characteristics |
Brain Dead Donor Accept an expedited liver recovered by any procurement team? |
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| Expedited Donor Characteristics |
DCD Donor Accept an expedited liver recovered by any procurement team? |
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| Expedited Donor Characteristics |
Max - Brain Dead Donor Acceptable donor age range |
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| Expedited Donor Characteristics |
Min - DCD Donor Acceptable donor age range |
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| Expedited Donor Characteristics |
Max - DCD Donor Acceptable donor age range |
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| Expedited Donor Characteristics |
Min - Brain Dead Donor Acceptable donor height range |
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| Expedited Donor Characteristics |
Max - Brain Dead Donor Acceptable donor height range |
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| Expedited Donor Characteristics |
Min - DCD Donor Acceptable donor height range |
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| Expedited Donor Characteristics |
Max - DCD Donor Acceptable donor height range |
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| Expedited Donor Characteristics |
Min - Brain Dead Donor Acceptable donor weight range |
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| Expedited Donor Characteristics |
Max - Brain Dead Donor Acceptable donor weight range |
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| Expedited Donor Characteristics |
Min - DCD Donor Acceptable donor weight range |
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| Expedited Donor Characteristics |
Max - DCD Donor Acceptable donor weight range |
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| Expedited Donor Characteristics |
Brain Dead Donor Acceptable maximum donor BMI |
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| Expedited Donor Characteristics |
DCD Donor Acceptable maximum donor BMI |
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| Expedited Donor Characteristics |
Brain Dead Donor Acceptable maximum distance from donor hospital (in nautical miles) |
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| Expedited Donor Characteristics |
DCD Donor Acceptable maximum distance from donor hospital (in nautical miles) |
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| Expedited Donor Characteristics |
Brain Dead Donor Acceptable maximum macrosteatosis % |
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| Expedited Donor Characteristics |
DCD Donor Acceptable maximum macrosteatosis % |
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| Verify ABO |
ABO |
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| HIV Verification |
Is the candidate HIV positive and willing to accept an HIV positive Liver? |
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| OMB No. 0915-0157; Expiration Date: XX/XX/20XX |
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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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov. |