Liver Recipient Explant Pathology Form

Liver Recipient Explant Pathology Form

Fields to be completed by members

Form Section

Field Label

Notes

Provider Information

Transplant Center Code//Recipient Center

Display Only - Cascades from TCR

Provider Information

Transplant Center Type//Recipient Center

Display Only - Cascades from TCR

Provider Information

Transplant Center

Display Only - Cascades from Database

Recipient Information

Recipient First Name//Name:

Display Only - Cascades from TCR

Recipient Information

Recipient Last Name//Name:

Display Only - Cascades from TCR

Recipient Information

Recipient Middle Initial//Name:

Display Only - Cascades from TCR

Recipient Information

Tx Date

Display Only - Cascades from Database

Recipient Information

Recipient SSN//SSN:

Display Only - Cascades from TCR

Recipient Information

DOB

Display Only - Cascades from Database

Recipient Information

Gender

Display Only - Cascades from TCR

Clinical Information

Was evidence of HCC (viable or non-viable tumor) found in the explant?

Clinical Information

Number of Tumors

Clinical Information

Tumor #1//Size

Clinical Information

Tumor #1//Location

Clinical Information

Tumor #1//Tumor Necrosis

Clinical Information

Tumor #2//Size

Clinical Information

Tumor #2//Location

Clinical Information

Tumor #2//Tumor Necrosis

Clinical Information

Tumor #3//Size

Clinical Information

Tumor #3//Location

Clinical Information

Tumor #3//Tumor Necrosis

Clinical Information

Tumor #4//Size

Clinical Information

Tumor #4//Location

Clinical Information

Tumor #4//Tumor Necrosis

Clinical Information

Tumor #5//Size

Clinical Information

Tumor #5//Location

Clinical Information

Tumor #5//Tumor Necrosis

Clinical Information

Worst Tumor Differentiation

Clinical Information

Vascular Invasion

Clinical Information

Lymph Node Involvement

Clinical Information

Other Extrahepatic Spread

Clinical Information

Satellite Lesions

Clinical Information

Did recipient receive any Ppre-transplant treatment liver-directed therapy for HCC?

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 0.7 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 Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.