UNOS ID* OPO* IIAM Placement Coordinator Cross-clamp Date* MM slash DD slash YYYY Cross-Clamp Time* : Hours Minutes WIT (in minutes, DCD Donor Only) In situ Flushing Solution & amount* Pancreas Storage Solution & amount* REQUIRED TISSUES - Pancreas, Spleen, Lymph Nodes & BloodPancreasPancreas* Yes No Entire pancreas and all peripancreatic fat (Surgical damage MAY be acceptable but MUST be reported to IIAM On-Call Coordinator).* Yes No Attached duodenum segment 5 – 10 cm, both ends MUST be stapled or closed with umbilical clamp & excised with pancreas.* Yes No Recovery issues please see comments section below* Yes No CommentsSpleenSpleen: (minimum of 1/3, preferably more)* Yes No Recovery issues please see comments section below* Yes No CommentsLymph NodesLymph nodes: 3-4 large nodes (mesenteric, inguinal or any other site)* Yes No Recovery issues please see comments section below* Yes No CommentsBloodBlood (please select one):* 26 weeks gestation - 4 years, 1 red top & 2 yellow or green top tubes 5-10 years, 2 red top & 4 yellow or green top tubes >10 years, 3 red top & 6 yellow or green top tubes Recovery issues please see comments section below Comments ***Blood containers must be placed inside the box, on top of the organ but not immersed in the ice to avoid freezing!*** Please Include the Following:Lots of wet ice and triple barrier packaging* Yes No Thymus (if required)* Yes No Bone marrow (if required)* Yes No Notify IIAM On-Call Coordinator of any surgical damage, anatomical anomalies, or any other variance from the recovery protocol prior to shipping the organ. CommentsConfirmed by:*