Adult Intestine Candidate Listing Registration

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

Adult Intestine Candidate Listing Registration

The fields on the Adult Intestine Candidate Listing Registration contain demographic and basic clinical information about candidates on the national waiting list.

Add New Candidate Registration

Transplant Hospital: Confirm the name of the transplant hospital.

Organ: Select Intestine.

Candidate Add

Center: Confirm the name of the transplant hospital.

Organ: Confirm organ selection.

Age group: Select the candidate’s age group.

SSN: Enter the candidate’s SSN number.

Note:  SSN cannot:

• Contain 00 in the 4th and 5th place (e.g. XXX-00-XXXX is invalid)

• Contain 0000 in the last 4 places (e.g. XXX-XX-0000 is invalid)

• Begin with 666

Confirm SSN: Confirm the candidate’s SSN number.

Provider Information

Transplant Center: Verify the transplant center name, and that the provider number is the 6-character Medicare identification number of the hospital where the transplant candidate is listed.

24 Hour Contact Phone Number: Verify the transplant center phone number.

Demographic Information

SSN: When adding a candidate, verify the transplant candidate's social security number.

Note:  SSN cannot:

• Contain 00 in the 4th and 5th place (e.g. XXX-00-XXXX is invalid)

• Contain 0000 in the last 4 places (e.g. XXX-XX-0000 is invalid)

• Begin with 666

Last Name: Enter the last name of the candidate. This is a required field.

First Name: Enter the first name of the candidate. This is a required field.

MI: Enter the candidate's middle initial.

DOB: Enter the candidate's date of birth. This is a required field.

Birth Sex: Indicate if the patient is Male or Female. Report patient sex (male or female), based on biologic and physiologic traits at birth. This is a required field.

Center's Patient ID: Enter the candidate's patient identification number that is assigned by your center, if applicable.

State of Permanent Residence: Select the full name of the state where the candidate's home is located.

Permanent Zip Code: Enter the 5-digit U.S. postal zip code for the address where the candidate's home is located. Note: Make corrections to an incorrect permanent zip code on the Transplant Candidate Registration (TCR) form in TIEDI^®. This field cannot be updated from the active list.

Ethnicity: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of ethnicity is aligned to this standard.

OMB defines ethnicity to be whether a person self-identifies as Hispanic origin or not. For this reason, ethnicity is broken out in two categories, (1) Hispanic or Latino or (2) Not Hispanic or Latino. Select one ethnicity category or select ‘Ethnicity Not Reported’ if the candidate did not self-identify. This field is required.

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Not Hispanic or Latino

Ethnicity Not Reported

Race: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of race is aligned to this standard. OMB defines race as a person’s self-identification with one or more social groups. ​

An individual can select one or more race categories (1) White, (2) Black or African American, (3) Asian, (4) American Indian or Alaska Native, (5) Native Hawaiian or Other Pacific Islander. Select 'Race Not Reported' if the candidate’s race is not reported.​ This field is required.​

Note: A person may report multiple races. Persons reporting Hispanic or Latino ethnicity may report themselves as any race category or report no race at all.

Select one or more race sub-categories or origins. Select 'Other Origin' if origin is not listed. Select 'Origin Not Reported' if the origin was not self-identified by the person.​​

White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.​

European Descent​

Arab or Middle Eastern​

North African (non-Black)​

Other Origin​

Origin Not Reported​​

Black or African American – A person having origins in any of the Black racial groups of Africa. ​

African American ​

African (Continental)​

West Indian​

Haitian​

Other Origin​

Origin Not Reported ​​

American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.​

American Indian​

Eskimo​

Aleutian​

Alaska Indian ​

Other Origin​

Origin Not Reported​

Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.​

Asian Indian/Indian Sub-Continent ​

Chinese​

Filipino​

Japanese​

Korean​

Vietnamese​

Other Origin​

Origin Not Reported ​

​Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.​

Native Hawaiian​

Guamanian or Chamorro​

Samoan​

Other Origin​

Origin Not Reported​

Race Not Reported – Select if person did not self-identify a race category or origin.​

Clinical Information

ABO: Select the candidate's blood type. This is a required field.

Note: A2 is used as shorthand for any blood type A subtype other than A1 (i.e., non-A1, negative for A1). A2B is used as shorthand for any blood type AB subtype other than A1B (i.e., non-A1B, negative for A1B). Policy requires at least two (2) separate blood typings prior to listing. Policy also requires you to review all known available blood type source documents to verify the candidate's blood type. See OPTN Policies for additional information. Use the search feature to locate specific policy information on ABO Typing.

O
A
B
AB
Z (in Utero Only)

Height: Enter the height of the candidate at the time of listing in the appropriate space, in feet and inches or centimeters. The height must fall between 0 and 7 feet or 1 and 241 centimeters. This is a required field.

Weight: Enter the weight of the candidate at the time of listing in the appropriate space, in pounds or kilograms. The weight must fall between 0 and 650 pounds or 0 and 295 kilograms. This is a required field.

HLA Class I

HLA: Histocompatibility antigens are currently not required when adding candidates for extra renal organs (LI, IN, HR, HL and LU) to the active list. If histocompatibility antigens are entered, at least one value is required for each antigen (A, B, Bw4, Bw6 and DR). The order in which the antigens are entered does not affect the matching and screening process.

A

A

B

B

BW4

BW6

C

C

HLA Class II

HLA: Histocompatibility antigens are currently not required when adding candidates for extra renal organs (LI, IN, HR, HL and LU) to the active list. If histocompatibility antigens are entered, at least one value is required for each antigen (A, B, Bw4, Bw6 and DR). The order in which the antigens are entered does not affect the matching and screening process.

DR

DR

DR51

DR51

DR52

DR52

DR53

DR53

DQB1

DQB1

DQA1

DQA1

DPB1

DPB1

DPA1

DPA1

Organ Information

Candidate Medical Urgency Status: Indicate the candidate's medical urgency status. If one of the Active statuses is selected, the candidate is eligible to appear on a UNet^SM match run. If temporarily inactive is selected, the candidate is non-eligible to appear on the UNet match run. This is a required field.

Note: See OPTN Policies for additional information. Use the search feature to locate specific policy information on Medical Urgency Status.

Status 1

Non-urgent

Temporarily Inactive

Inactive reason: Select the reason the candidate is inactive.

 

Inactive Reason Code	Description
1	Candidate cannot be contacted
2	Candidate choice
3	Candidate work-up incomplete
4	Insurance issues
5	Medical non-compliance
6	Inappropriate substance use
7	Temporarily too sick
8	Temporarily too well
9	Weight currently inappropriate for transplant
10	Transplanted - removal pending UNET data correction
11	Inactivation due to VAD implantation and/or VAD complication
12	TX Pending
13	Physician/Surgeon unavailable
14	Candidate for living donor transplant only
16	COVID-19 Precaution

 

 Note: The inactive reason TX'ed - removal pending UNet data correction is only to be used when a transplant center removed the incorrect candidate from Waitlist due to transplant and is waiting for UNOS to correct the data so that the correct candidate can be removed with the right donor ID. Candidates should not be set to inactive for this reason for more than 5 days.

Preliminary Crossmatch Required: Select Yes, if a preliminary cross-match is required.  If it is not, select No.

Accept intestine if removed by another procurement team?: Select Yes, if the candidate will accept an intestine if removed by another procurement team.  If not, select No.

Accept intestine if kidney procured?: Select Yes, if the candidate will accept an intestine if a kidney is procured. If not, select No.

Accept intestine if pancreas procured?: Select Yes, if the candidate will accept an intestine if a pancreas is procured. If not, select No.

Accept intestine if liver procured?: Select Yes, if the candidate will accept an intestine if a liver is procured. If not, select No.

Number of previous Intestine Transplants: Indicate the number of candidate's previous intestine transplants. This is a required field.

Status 1 Justification Form

Status: The candidate's listing status is displayed.

Surgeon/Physician NPI: Enter the NPI of the candidate's surgeon/physician. This is a required field.

Surgeon/Physician Name: Enter the name of the candidate's surgeon/physician. This is a required field.

Hospital Telephone Number: Enter the transplant hospital's telephone number. This is a required field.

Primary Diagnosis: Select the primary cause of intestine failure from the list provided. 

Specify: If the primary cause of intestine failure is not listed, select Specify and enter the primary cause of intestine failure in the space provided.

Secondary Diagnosis: Select the secondary cause of intestine failure from the list provided. 

Specify: If the secondary cause of intestine failure is not listed, select Specify and enter the secondary cause of intestine failure in the space provided.

In order to qualify as Status 1, at least one of the following conditions must exist (please complete the following fields):

The candidate no longer has vascular access through the subclavian, jugular or femoral veins for intravenous feeding.: Select Yes or No.

The candidate has abnormal liver function test values: Indicate whether the candidate has abnormal liver function test values by selecting Yes or No.  If Yes is selected, indicate the Value and Date for each test listed below.

Total Bilirubin (mg/dL): Enter the lab value for total serum bilirubin in mg/dl.

 

Alkaline Phosphate (units/L): Enter the lab value for the serum alkaline phosphate value in units/L.

 

SGOT/AST (U/mL): Enter the lab value for the serum glutamic oxaloacetic transaminase or aspartate transaminase in U/L.

 

SGPT/ALT (U/mL): (Serum Glutamic Pyruvic Transaminase/Alanine Aminotransferase): Enter the lab value for this enzyme in U/L.

 

Albumin (g/dL): Enter the lab value for the serum albumin value in g/dl.

 

INR: International Normalized Ratio.  Enter the ratio of the prothrombin time (in seconds) to the control prothrombin time (in seconds).

 

Other: Indicate if other conditions exist to require the candidate to be listed at Status 1 by selecting Yes or No. This is a required field.

 

Justification Narrative:  Enter a clinical narrative in the space provided. This is a required field for all Status 1 candidates.

 

Note: If the candidate does not have abnormal liver function test values, the lab test Dates and Values are not required.

Additional Organs

Check any additional organs that the candidate may need. Checking organ(s) within this section will not register the candidate on the checked organ waiting list. You will need to complete a registration and verify the accuracy of donor acceptance criteria for each additional organ checked.

Kidney

Pancreas

Pancreas Islet

Liver

Heart

Heart/Lung

Lung

Donor Characteristics

Minimum acceptable donor age: Enter the minimum donor age that the candidate can accept for local and import offers. The age must fall between 0 and 99 years. This field is required.

Maximum acceptable donor age: Enter the maximum donor age that the candidate can accept for local and import offers. The age must fall between 0 and 99 years. The maximum value must only be entered in months if the minimum value is also entered in months (e.g. you are able enter that you will accept donors from 3 months to 3 years in age, but you may NOT enter that you would accept a donor from 1 year to 36 months in age). This field is required.

Minimum acceptable donor weight: Enter the minimum donor weight that the candidate can accept for local and import offers. The weight must be a whole number that falls between 0 and 440 pounds, or 0 and 200 kilograms. The minimum acceptable donor weight should be no more than 30 percent (30%) below the candidate's listing weight. To eliminate the possibility of conversion errors or rounding issues, the match system deducts .5 kg before comparing this value to the donor’s weight. This field is required.  

Maximum acceptable donor weight: Enter the maximum donor weight that the candidate can accept for local and import offers. The weight must be a whole number that falls between 0 and 440 pounds, or 0 and 200 kilograms. The maximum acceptable donor weight must be more than the candidate's listing weight, and must be greater than the minimum acceptable donor weight. To eliminate the possibility of conversion errors or rounding issues, the match system deducts .5 kg before comparing this value to the donor’s weight. This field is required.  

Maximum acceptable donor BMI: Enter the maximum donor body mass index (BMI) in kilogram-meter squared (kg/m²) that the candidate can accept. The BMI must fall between 5.0 and 100.0 kg/m².

Accept DCD donor: Select Yes if the candidate will accept a DCD (Donation after Circulatory Death) donor for local and import offers. If not, select No. Donation after Circulatory Death (DCD) describes the organ recovery process that may occur following death by irreversible cessation of circulatory and respiratory functions. A DCD donor may also be called a non-heartbeating, asystolic, or donation after cardiac death donor. This field is required.

Medical and Social History

Accept donor with a history of gastrointestinal disease?: Select Yes if the candidate will accept a donor with a history of gastrointestinal disease. If not, select No.

Accept a donor with a history of diabetes?: Select Yes if the candidate will accept a donor with a history of diabetes. If not, select No. A donor should not be considered as having a history of diabetes based on gestational diabetes only.

Infectious Diseases

Accept a Hepatitis B Core antibody positive donor?: Select Yes if the candidate will accept a Hepatitis B core antibody positive donor. If not, select No. This field is required.

Accept an HBV NAT positive donor?: Select Yes if the candidate will accept an HBV NAT positive donor. If not, select No This field is required.

Accept an HCV antibody positive donor?: Select Yes if the candidate will accept an HCV antibody positive donor. If not, select No. This field is required.

Accept an HCV NAT positive donor?: Select Yes if the candidate will accept an HCV NAT positive donor. If not, select No. This field is required.

Accept a CMV antibody positive donor?: Select Yes if the candidate will accept an CMV antibody positive donor. If not, select No. This field is required.

 

Recovery

Maximum miles the organ or recovery team will travel: Enter the maximum miles the candidate's organ or recovery team will travel to obtain an organ. The number must fall between 0 and 9,999 miles. This field is required.

The matching system calculates mileage between the donor hospital and the recipient center based on the hospitals' zip codes. This distance is measured in nautical miles (a measure of flight distance), not in statute miles (a measurement of driving distance).

Conversion Table for Nautical and Statute Miles

Nautical Miles	Statute Miles
250	287.7
500	575.4
1000	1150.8
1500	1726.2
2000	2301.6
2500	2876.9

 

 

 

 

 

 

 

 

 

Lab Values

Maximum acceptable donor Serum Creatinine - Peak: Enter the donor maximum acceptable peak serum creatinine that the candidate can accept in milligrams per deciliter (mg/dL). The number must fall between 0.0 and 10.0 mg/dL.

Maximum acceptable donor Serum Creatinine - Final: Enter the donor maximum acceptable final serum creatinine that the candidate can accept in milligrams per deciliter (mg/dL). The number must fall between 0.0 and 10.0 mg/dL.

Maximum acceptable donor SGOT (AST) - Peak: Enter the donor's maximum acceptable peak serum aspartate transaminase (AST/SGOT) that the candidate can accept in units per liter (u/L). The number must fall between 1 and 36,000 u/L.

Maximum acceptable donor SGPT (ALT) - Peak: Enter the donor's maximum acceptable peak ALT (alanine amino transferase, also called SGPT) that the candidate can accept in units per liter (u/L). The number must fall between 1 and 50,000 u/L.

Maximum acceptable donor Serum Amylase - Peak: Enter the donor's maximum acceptable peak serum amylase that the candidate can accept in units per liter (u/L). The number must fall between 0.00 and 9,999.00 u/L.

Maximum acceptable donor Serum Lipase - Peak: Enter the donor's maximum acceptable peak serum lipase that the candidate can accept in units per liter (u/L). The number must fall between 0.00 and 9,999.00 u/L.

Unacceptable Antigens

Select all of the unacceptable antigens and then click the "Calculate" button for the CPRA score.

CPRA: Calculated Panel Reactive Antibody (CPRA) is the percentage of deceased donors expected to have one or more of the unacceptable antigens indicated on the waiting list for the candidate. The CPRA is derived from HLA antigen, allele, and epitope genotype frequencies for the different populations in proportion to their representation in the national deceased donor population.

Percent CPRA: The value rounded to the nearest one-hundredth and displayed with a % symbol. 

Detailed CPRA: The value displayed as a decimal to 6 digits of precision.

Select all A unacceptable antigens: Select the candidate's A unacceptable antigens, if applicable. Make your selections from the left-hand column and click the arrow to add or remove them to the right-hand column.

Select all B unacceptable antigens: Select the candidate's B unacceptable antigens, if applicable. Make your selections from the left-hand column and click the arrow to add or remove them to the right-hand column.

Select BW unacceptable antigen: Select the candidate's BW unacceptable antigen, if applicable. Make your selections from the left-hand column and click the arrow to add or remove them to the right-hand column.

Select all C unacceptable antigens: Select the candidate's C unacceptable antigens, if applicable. Make your selections from the left-hand column and click the arrow to add or remove them to the right-hand column.

Select all DR unacceptable antigens: Select the candidate's DR unacceptable antigens, if applicable. Make your selections from the left-hand column and click the arrow to add or remove them to the right-hand column.

Select all DR 51/52/53 unacceptable antigens: Select the candidate's DR 51, 52 and 53 unacceptable antigens, if applicable. Make your selections from the left-hand column and click the arrow to add or remove them to the right-hand column.

Select all DQB1 unacceptable antigens: Select the candidate's DQB1 unacceptable antigens, if applicable. Make your selections from the left-hand column and click the arrow to add or remove them to the right-hand column.

Select all DQA1 unacceptable antigens: Select the candidate's DQA1 unacceptable antigens, if applicable. Make your selections from the left-hand column and click the arrow to add or remove them to the right-hand column.

Select all DPB1 unacceptable antigens: Select the candidate's DPB1 unacceptable antigens, if applicable. Make your selections from the left-hand column and click the arrow to add or remove them to the right-hand column.

Select all DPB1 unacceptable epitopes: Select the candidate's DPB1 unacceptable epitopes, if applicable. Make your selections from the left-hand column and click the arrow to add or remove them to the right-hand column.

Select all DPA1 unacceptable antigens: Select the candidate's DPA1 unacceptable antigens, if applicable. Make your selections from the left-hand column and click the arrow to add or remove them to the right-hand column.

 

ABO

ABO: Verify the candidate’s blood type.

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.   

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