| Candidate Registration Listing Removal |
| Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
| Provider Information |
Transplant Center |
Display Only - Cascades from Database |
| Provider Information |
24 Hour Contact Phone Number |
Display Only - Cascades from Database |
| Demographic Information |
SSN |
Display Only - Cascades from Database |
| Demographic Information |
Name |
Display Only - Cascades from Database |
| Demographic Information |
Birth Sex |
Display Only - Cascades from Database |
| Demographic Information |
DOB |
Display Only - Cascades from Database |
| Demographic Information |
ABO |
Display Only - Cascades from Database |
| Demographic Information |
State of Permanent Residence |
Display Only - Cascades from Database |
| Demographic Information |
Permanent Zip Code |
Display Only - Cascades from Database |
| Demographic Information |
Ethnicity |
Display Only - Cascades from Database |
| Demographic Information |
Select all origins that apply |
Display Only - Cascades from Database |
| Demographic Information |
Race |
Display Only - Cascades from Database |
| Removal Code 4, 15, 21 |
Donor ID |
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| Removal Code 4, 15, 21 |
Donor OPO |
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| Removal Code 4, 15, 21 |
Donor Organ Received |
Display Only - Cascades from Database |
| Removal Code 4, 15, 21 |
Organ Type |
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| Removal Code 4, 15, 21 |
Transplant Date |
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| Removal Code 4, 15, 21 |
Were extra vessels used in the transplant procedure |
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| Removal Code 4, 15, 21 |
Vessel Donor ID |
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| Removal Code 4, 15, 21 |
Did the patient receive any other organ transplant at this time |
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| Removal Code 4, 15, 21 |
Recipient Histocompatibility Laboratory |
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| Removal Code 8 |
Did the patient go to the operating room and receive anesthesia for transplant prior to death? |
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| Removal Code 8 |
Was anastomosis initiated? |
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| Removal Code 8 |
Did the death occur before the cavity was closed and after the final stitch and/or staple was applied? |
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| Removal Code 8 |
Date of Death |
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| Removal Code 8 |
Cause of Death |
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| Removal Code 8 |
Other Specify |
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| Removal Code 9 |
Specify the Reason |
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| Removal Code 22 |
Country |
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| Remove Kidney-Pancreas Candidate |
Medical Urgency Status |
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| Remove Kidney-Pancreas Candidate |
Inactive Reason |
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| Remove Kidney-Pancreas Candidate |
Has the candidate had a prior Kidney Transplant? |
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| Remove Kidney-Pancreas Candidate |
If yes, is the kidney graft still functioning? |
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| Remove Kidney-Pancreas Candidate |
A |
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| Remove Kidney-Pancreas Candidate |
A |
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| Remove Kidney-Pancreas Candidate |
B |
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| Remove Kidney-Pancreas Candidate |
B |
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| Remove Kidney-Pancreas Candidate |
BW4 |
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| Remove Kidney-Pancreas Candidate |
BW6 |
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| Remove Kidney-Pancreas Candidate |
C |
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| Remove Kidney-Pancreas Candidate |
C |
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| Remove Kidney-Pancreas Candidate |
DR |
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| Remove Kidney-Pancreas Candidate |
DR |
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| Remove Kidney-Pancreas Candidate |
DR51 |
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| Remove Kidney-Pancreas Candidate |
DR51 |
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| Remove Kidney-Pancreas Candidate |
DR52 |
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| Remove Kidney-Pancreas Candidate |
DR52 |
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| Remove Kidney-Pancreas Candidate |
DR53 |
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| Remove Kidney-Pancreas Candidate |
DR53 |
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| Remove Kidney-Pancreas Candidate |
DQB1 |
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| Remove Kidney-Pancreas Candidate |
DQB1 |
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| Remove Kidney-Pancreas Candidate |
DQA1 |
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| Remove Kidney-Pancreas Candidate |
DQA1 |
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| Remove Kidney-Pancreas Candidate |
DPB1 |
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| Remove Kidney-Pancreas Candidate |
DPB1 |
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| Remove Kidney-Pancreas Candidate |
DPA1 |
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| Remove Kidney-Pancreas Candidate |
DPA1 |
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| Remove Kidney-Pancreas Candidate - Ped |
Medical Urgency Status |
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| Remove Kidney-Pancreas Candidate - Ped |
Inactive Reason |
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| Remove Kidney-Pancreas Candidate - Ped |
Has the candidate had a prior Kidney Transplant? |
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| Remove Kidney-Pancreas Candidate - Ped |
If yes, is the kidney graft still functioning? |
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| Remove Kidney-Pancreas Candidate - Ped |
A |
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| Remove Kidney-Pancreas Candidate - Ped |
A |
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| Remove Kidney-Pancreas Candidate - Ped |
B |
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| Remove Kidney-Pancreas Candidate - Ped |
B |
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| Remove Kidney-Pancreas Candidate - Ped |
BW4 |
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| Remove Kidney-Pancreas Candidate - Ped |
BW6 |
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| Remove Kidney-Pancreas Candidate - Ped |
C |
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| Remove Kidney-Pancreas Candidate - Ped |
C |
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| Remove Kidney-Pancreas Candidate - Ped |
DR |
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| Remove Kidney-Pancreas Candidate - Ped |
DR |
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| Remove Kidney-Pancreas Candidate - Ped |
DR51 |
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| Remove Kidney-Pancreas Candidate - Ped |
DR51 |
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| Remove Kidney-Pancreas Candidate - Ped |
DR52 |
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| Remove Kidney-Pancreas Candidate - Ped |
DR52 |
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| Remove Kidney-Pancreas Candidate - Ped |
DR53 |
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| Remove Kidney-Pancreas Candidate - Ped |
DR53 |
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| Remove Kidney-Pancreas Candidate - Ped |
DQB1 |
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| Remove Kidney-Pancreas Candidate - Ped |
DQB1 |
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| Remove Kidney-Pancreas Candidate - Ped |
DQA1 |
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| Remove Kidney-Pancreas Candidate - Ped |
DQA1 |
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| Remove Kidney-Pancreas Candidate - Ped |
DPB1 |
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| Remove Kidney-Pancreas Candidate - Ped |
DPB1 |
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| Remove Kidney-Pancreas Candidate - Ped |
DPA1 |
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| Remove Kidney-Pancreas Candidate - Ped |
DPA1 |
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| Remove Pancreas Islets Candidate |
Total Infusions With This Transplant |
Display Only |
| Remove Pancreas Islets Candidate |
Re-List Candidate? |
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| Remove Pancreas Islets Candidate - Ped |
Total Infusions With This Transplant |
Display Only |
| Remove Pancreas Islets Candidate - Ped |
Re-List Candidate? |
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| Remove Liver Candidate |
Copy most recent MELD/PELD labs from above |
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| Remove Liver Candidate |
Serum Creatinine |
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| Remove Liver Candidate |
Test Date |
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| Remove Liver Candidate |
Had dialysis twice, or 24 hours of CVVHD, within a week prior to the serum creatinine test? |
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| Remove Liver Candidate |
Serum Sodium |
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| Remove Liver Candidate |
Test Date |
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| Remove Liver Candidate |
Encephalopathy |
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| Remove Liver Candidate |
Ascites |
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| Remove Liver Candidate |
Bilirubin (mg/dL) |
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| Remove Liver Candidate |
Value |
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| Remove Liver Candidate |
Albumin (g/dL) |
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| Remove Liver Candidate |
Value |
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| Remove Liver Candidate |
INR |
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| Remove Liver Candidate |
Value |
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| Remove Liver Candidate |
Bilirubin (mg/dL) (PBC/PSC/Other Cholestatic) |
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| Remove Liver Candidate - Ped |
Copy most recent MELD/PELD labs from above |
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| Remove Liver Candidate - Ped |
Serum Creatinine |
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| Remove Liver Candidate - Ped |
Test Date |
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| Remove Liver Candidate - Ped |
Had dialysis twice, or 24 hours of CVVHD, within a week prior to the serum creatinine test? |
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| Remove Liver Candidate - Ped |
Serum Sodium |
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| Remove Liver Candidate - Ped |
Test Date |
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| Remove Liver Candidate - Ped |
Encephalopathy |
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| Remove Liver Candidate - Ped |
Ascites |
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| Remove Liver Candidate - Ped |
Bilirubin (mg/dL) |
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| Remove Liver Candidate - Ped |
Value |
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| Remove Liver Candidate - Ped |
Albumin (g/dL) |
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| Remove Liver Candidate - Ped |
Value |
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| Remove Liver Candidate - Ped |
INR |
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| Remove Liver Candidate - Ped |
Value |
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| Remove Liver Candidate - Ped |
Bilirubin (mg/dL) (PBC/PSC/Other Cholestatic) |
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| Remove Heart Candidate |
Has the candidate ever had any of the following devices? |
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| Remove Heart Candidate |
Device Type |
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| Remove Heart Candidate |
Device Brand |
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| Remove Heart Candidate |
Specify |
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| Remove Heart Candidate |
Implant Date |
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| Remove Heart Candidate |
In Place |
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| Remove Heart Candidate |
Explant Date |
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| Remove Heart Candidate |
Explant Reason |
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| Remove Heart Candidate |
Ventricle Support |
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| Remove Heart Candidate - Ped |
Has the candidate ever had any of the following devices? |
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| Remove Heart Candidate - Ped |
Device Type |
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| Remove Heart Candidate - Ped |
Device Brand |
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| Remove Heart Candidate - Ped |
Specify |
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| Remove Heart Candidate - Ped |
Implant Date |
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| Remove Heart Candidate - Ped |
In Place |
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| Remove Heart Candidate - Ped |
Explant Date |
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| Remove Heart Candidate - Ped |
Explant Reason |
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| Remove Heart Candidate - Ped |
Ventricle Support |
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| Remove Lung Candidate |
Has the candidate had ventilatory support (i.e., ECMO, invasive mechanical ventilation) for respiratory failure since registration? |
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| Remove Lung Candidate |
Device Type |
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| Remove Lung Candidate |
Site |
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| Remove Lung Candidate |
Ambulatory Status |
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| Remove Lung Candidate |
Cannulation Date |
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| Remove Lung Candidate |
Intubation Date |
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| Remove Lung Candidate |
In Place |
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| Remove Lung Candidate |
Decannulation Date |
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| Remove Lung Candidate |
Extubation Date |
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| Remove Lung Candidate - Ped |
Has the candidate had ventilatory support (i.e., ECMO, invasive mechanical ventilation) for respiratory failure since registration? |
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| Remove Lung Candidate - Ped |
Device Type |
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| Remove Lung Candidate - Ped |
Site |
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| Remove Lung Candidate - Ped |
Ambulatory Status |
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| Remove Lung Candidate - Ped |
Cannulation Date |
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| Remove Lung Candidate - Ped |
Intubation Date |
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| Remove Lung Candidate - Ped |
In Place |
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| Remove Lung Candidate - Ped |
Decannulation Date |
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| Remove Lung Candidate - Ped |
Extubation Date |
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| Remove Heart/Lung Candidate |
Has the candidate ever had any of the following devices? |
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| Remove Heart/Lung Candidate |
Device Type |
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| Remove Heart/Lung Candidate |
Device Brand |
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| Remove Heart/Lung Candidate |
Specify |
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| Remove Heart/Lung Candidate |
Implant Date |
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| Remove Heart/Lung Candidate |
In Place |
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| Remove Heart/Lung Candidate |
Explant Date |
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| Remove Heart/Lung Candidate |
Explant Reason |
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| Remove Heart/Lung Candidate - Ped |
Has the candidate ever had any of the following devices? |
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| Remove Heart/Lung Candidate - Ped |
Device Type |
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| Remove Heart/Lung Candidate - Ped |
Device Brand |
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| Remove Heart/Lung Candidate - Ped |
Specify |
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| Remove Heart/Lung Candidate - Ped |
Implant Date |
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| Remove Heart/Lung Candidate - Ped |
In Place |
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| Remove Heart/Lung Candidate - Ped |
Explant Date |
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| Remove Heart/Lung Candidate - Ped |
Explant Reason |
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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. |