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American Transplant Foundation

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Living Donor Database

Manager: Anastasia Henry

Company:

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Potential Living Donors Recipient Profiles Recipient Surveys Potential Donor Survey Recipient Testimonials

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Show your data in a spreadsheet-style report with rows and columns.

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Group and total your data to answer questions about large data sets.

Visualize your data in charts including pie, bar, line and others.

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Welcome!

Thank you very much for your interest in being a living donor. Welcome to the first-of-its-kind Potential Living Donor Database with the American Transplant Foundation.

The information collected is used to understand where you are along the transplant journey and how our organization can best help you reach your transplant journey goals. Please note that this database is meant to provide you with guidance and support as you consider living donation. It is not a living donor registry and will not determine if you are able to be a living donor nor match you directly with someone in need of a donor. Only a medical professional can determine your eligibility to be a living donor and if you are a match for a specific transplant recipient candidate.

Please be advised, it is absolutely against the law to financially benefit from organ donation. You must be at least 18 years old to apply. Please submit your information completely and as requested. If you complete any fields with false information your profile will be removed. Thank you very much for your interest in becoming a living donor and saving a life.

Do you reside in the United States? *

I have reviewed and understand the above information: *

Potential Living Donor Name & Contact Information

Potential Living Donor First Name *

Potential Living Donor Last Name *

Primary Phone Number *

Secondary Phone Number

Email *

Preferred Contact Method

Personal Information

Primary Language *

State *

Demographic Information

Date of Birth

Age

Note: For date of birth, you may type out or scroll through dates. Please use this format: 01-04-1972.

Gender

Ethnicity *

Potential Living Donation Information

Generally, these are the characteristics of excellent candidates for living organ donation:
- free from high blood pressure, diabetes, cancer, HIV, hepatitis, or organ-specific diseases
- be well informed about risks, benefits, and potential outcomes
- (generally) body mass index less than 35
- have good support from family and friends
- no alcohol or substance abuse problems
- have psychiatric diagnoses well controlled over an extended period of time

Do you feel like you will be a good candidate for living donation based on these general guidelines?

I believe I will be a good candidate. *

Type of Living Donation Interested In: *

Other

Comments

Are you willing to travel out of state to be a living donor? *

Blood Type

Race/Ethnicity (select all that apply) *

Potential Transplant Recipient

Do you have an individual in mind you would like to test for? If so, please complete this section with his/her name and transplant center (if known).

Potential Recipient First Name

Potential Recipient Last Name

Potential Recipient's Transplant Center

Transplant Center State/Location

Additional Information

Why do you want to donate? *

How did you hear about us? *

If other, please provide how you heard about us here:

What else would you like us to know?

I would like to receive periodic emails (usually quarterly) about the American Transplant Foundation's exciting events, programs, valuable resources, news, and inspiring patient testimonials.

This program is completely free to potential living donors and those on the transplant waitlist. You can support this lifesaving initiative and more by joining our monthly giving program Save a Life Giving Club. Any amount makes a big impact!

Also, follow us on social media to stay up to date on everything ATF!

Disclaimer and Signature

As a potential living donor, I have truthfully, accurately, and completely provided all the information requested in the application for living organ donation for the American Transplant Foundation's (ATF) confidential Potential Living Donor Database. I understand that only a transplant center can determine if I am eligible to be a living donor and that the American Transplant Foundation nor any of its employees or volunteers have a say in the matter. I also understand that being a living organ donor is the sole decision made by the potential donor and I can withdraw at any moment for any reason. I understand that the information provided will be for American Transplant Foundation's use only.

Signature *

Date Signed

Please expect an email within the next week from one of our Living Donor Ambassadors, who are living donors themselves and can answer any questions you may have!
Thank you for taking the first step towards saving a life!

To submit your form, please simply click the green "Save and Close" button

P.S. Our programs are completely free to those who need it. You can further support our lifesaving initiatives by joining our monthly giving program Save a Life Giving Club. Any amount makes a big impact!

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Yes. You can provide "Help" to your users for any field:

1. On any page in your application, click "Customize" then "Fields". If it is a multi-table application, select the table.

2. Click the "Edit" button next to the field for which you want to add an annotation.

3. In the "Help" text input box, enter text that will assist your users, and click "Save".

Your text will appear when the user hovers over or clicks on the question mark icon next to that field on the Add Record and Edit Record pages.

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Client Performance Report

Network latency: ()

The time taken for page load once the page is received from the server:()

The total process of navigation and page load: ()

From inline js at page top..
        .. to the time until docready:( s)
        .. to the time until window load begins: ( s)
        .. to the time until window load ends: ( s)

You've made changes to this Potential Living Donor. Do you want to save these changes before going to the next screen?

Report Name *

Description

Show description on report page

Reports and Charts Panel

Each table has a panel listing its reports and charts, organized in groups.

Print the report as a table

Print one Potential Living Donor per page ( total)

Print as much of the timeline as fits on a single page

Print the timeline over multiple letter-size pages in landscape orientation

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Living Donor Database

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Can I annotate fields to indicate their intended use?

Client Performance Report

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Quickbase will send a report of the events currently displayed on your calendar.
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To Paste
To paste clipboard data that comes from another program right-click on the text area below, select Paste, then click OK.



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