| Pediatric Heart Candidate Listing Registration |
| Fields to be completed by members |
|
|
|
| Form Section |
Field Label |
Notes |
| Add new candidate registration |
Transplant Hospital |
Display only - Cascade from database |
| Add new candidate registration |
Organ |
|
| Candidate Add |
Center |
Display only - Cascade from database |
| Candidate Add |
Organ |
Display only - Cascade from database |
| Candidate Add |
Age group |
|
| Candidate Add |
SSN |
|
| Candidate Add |
Confirm SSN |
|
| Provider Information |
Transplant Center |
Display only - Cascade from database |
| Provider Information |
24 hour contact phone number |
|
| Demographic Information |
SSN |
|
| Demographic Information |
Confirm SSN |
|
| Demographic Information |
Last Name |
|
| Demographic Information |
First Name |
|
| Demographic Information |
MI |
|
| Demographic Information |
Date of birth |
|
| Demographic Information |
Confirm date of birth |
|
| Demographic Information |
Birth sex |
|
| Demographic Information |
Center's patient ID |
|
| Demographic Information |
State of Permanent Residence |
|
| Demographic Information |
Permanent ZIP Code |
|
| Demographic Information |
Ethnicity |
|
| Demographic Information |
Race |
|
| Clinical Information |
ABO |
|
| Clinical Information |
Accept an Intended Blood Group Incompatible Organ? |
|
| Clinical Information |
Height (ft) |
|
| Clinical Information |
Height (in) |
|
| Clinical Information |
Height (cm) |
|
| Clinical Information |
Weight (lbs) |
|
| Clinical Information |
Weight (kg) |
|
| HLA CLASS I |
A |
|
| HLA CLASS I |
A |
|
| HLA CLASS I |
B |
|
| HLA CLASS I |
B |
|
| HLA CLASS I |
BW4 |
|
| HLA CLASS I |
BW6 |
|
| HLA CLASS I |
C |
|
| HLA CLASS I |
C |
|
| HLA CLASS II |
DR |
|
| HLA CLASS II |
DR |
|
| HLA CLASS II |
DR51 |
|
| HLA CLASS II |
DR51 |
|
| HLA CLASS II |
DR52 |
|
| HLA CLASS II |
DR52 |
|
| HLA CLASS II |
DR53 |
|
| HLA CLASS II |
DR53 |
|
| HLA CLASS II |
DQB1 |
|
| HLA CLASS II |
DQB1 |
|
| HLA CLASS II |
DQA1 |
|
| HLA CLASS II |
DQA1 |
|
| HLA CLASS II |
DPB1 |
|
| HLA CLASS II |
DPB1 |
|
| HLA CLASS II |
DPA1 |
|
| HLA CLASS II |
DPA1 |
|
| Confirm HLA CLASS I |
A |
|
| Confirm HLA CLASS I |
A |
|
| Confirm HLA CLASS I |
B |
|
| Confirm HLA CLASS I |
B |
|
| Confirm HLA CLASS I |
BW4 |
|
| Confirm HLA CLASS I |
BW6 |
|
| Confirm HLA CLASS I |
C |
|
| Confirm HLA CLASS I |
C |
|
| Confirm HLA CLASS II |
DR |
|
| Confirm HLA CLASS II |
DR |
|
| Confirm HLA CLASS II |
DR51 |
|
| Confirm HLA CLASS II |
DR51 |
|
| Confirm HLA CLASS II |
DR52 |
|
| Confirm HLA CLASS II |
DR52 |
|
| Confirm HLA CLASS II |
DR53 |
|
| Confirm HLA CLASS II |
DR53 |
|
| Confirm HLA CLASS II |
DQB1 |
|
| Confirm HLA CLASS II |
DQB1 |
|
| Confirm HLA CLASS II |
DQA1 |
|
| Confirm HLA CLASS II |
DQA1 |
|
| Confirm HLA CLASS II |
DPB1 |
|
| Confirm HLA CLASS II |
DPB1 |
|
| Confirm HLA CLASS II |
DPA1 |
|
| Confirm HLA CLASS II |
DPA1 |
|
| Organ Information |
Candidate Medical Urgency Status |
|
| Organ Information |
Inactive Reason |
|
| Organ Information |
Heart Diagnosis Code |
|
| Organ Information |
Preliminary Crossmatch Required |
|
| Organ Information |
Number of previous Heart Transplants |
|
| Justification Form Status 1A |
Patient must meet one of the following criteria |
|
| Justification Form Status 1A |
Congenital Heart Disease Diagnosis |
|
| Justification Form Status 1A |
Other |
|
| Justification Form Status 1A |
Dobutamine |
|
| Justification Form Status 1A |
Dopamine |
|
| Justification Form Status 1A |
Milrinone |
|
| Justification Form Status 1A |
Epinephrine |
|
| Justification Form Status 1A |
Norepinephrine (Levophed) |
|
| Justification Form Status 1A |
IV Nitroglycerin |
|
| Justification Form Status 1A |
Nesiritide (Natrecor) |
|
| Justification Form Status 1A |
Nitroprusside (Nipride, Nitropress) |
|
| Justification Form Status 1A |
Phenylephrine (Neo-Synephrine) |
|
| Justification Form Status 1A |
Vasopressin (Pitressin) |
|
| Justification Form Status 1A |
Narrative |
|
| Justification Form Status 1A |
Surgeon/Physician NPI |
|
| Justification Form Status 1A |
Surgeon/Physician Name |
|
| Justification Form Status 1A |
Email Addresses |
|
| Justification Form Status 1B |
Patient must meet one of the following criteria |
|
| Justification Form Status 1B |
Hypertrophic or Restrictive Cardiomyopathy |
|
| Justification Form Status 1B |
Justification Narrative |
|
| Justification Form Status 1B |
Surgeon/Physician NPI |
|
| Justification Form Status 1B |
Surgeon/Physician Name |
|
| Justification Form Status 1B |
Email Addresses |
|
| Additional Organs |
Check any additional organs the candidate may need. |
|
| Donor Characteristics |
Local Minimum acceptable donor age |
|
| Donor Characteristics |
Import Minimum acceptable donor age |
|
| Donor Characteristics |
Local Maximum acceptable donor age |
|
| Donor Characteristics |
Import Maximum acceptable donor age |
|
| Donor Characteristics |
Local Minimum acceptable donor height |
|
| Donor Characteristics |
Import Minimum acceptable donor height |
|
| Donor Characteristics |
Local Maximum acceptable donor height |
|
| Donor Characteristics |
Import Maximum acceptable donor height |
|
| Donor Characteristics |
Local Minimum acceptable donor weight |
|
| Donor Characteristics |
Import Minimum acceptable donor weight |
|
| Donor Characteristics |
Local Maximum acceptable donor weight |
|
| Donor Characteristics |
Import Maximum acceptable donor weight |
|
| Donor Characteristics |
Donor Birth Sex requirements |
|
| Donor Characteristics |
Local Accept DCD donor? |
|
| Donor Characteristics |
Import Accept DCD donor? |
|
| Medical and Social History |
Accept a donor with a history of coronary artery disease? |
|
| Infectious diseases |
Accept a Hepatitis B core antibody positive donor? |
|
| Infectious diseases |
Accept an HBV NAT positive donor? |
|
| Infectious diseases |
Accept an HCV antibody positive donor? |
|
| Infectious diseases |
Accept an HCV NAT positive donor? |
|
| Recovery |
Maximum nautical miles the organ or recovery team will travel |
|
| Unacceptable Antigens |
A |
|
| Unacceptable Antigens |
B |
|
| Unacceptable Antigens |
BW |
|
| Unacceptable Antigens |
C |
|
| Unacceptable Antigens |
DR |
|
| Unacceptable Antigens |
DR51 |
|
| Unacceptable Antigens |
DR52 |
|
| Unacceptable Antigens |
DR53 |
|
| Unacceptable Antigens |
DQB1 |
|
| Unacceptable Antigens |
DQA1 |
|
| Unacceptable Antigens |
DPB1 - unacceptable antigens |
|
| Unacceptable Antigens |
DPB1 - unacceptable epitopes |
|
| Unacceptable Antigens |
DPA1 |
|
| Verify ABO |
ABO |
|
|
|
|
|
|
|
| OMB No. 0915-0157; Expiration Date: XX/XX/20XX |
|
|
| 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. |