Preservation Payroll Form

GENERAL INFORMATION

*

UNOS

*

TITLE

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* PRESERVATIONIST NAME
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CASE TYPE

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ACTIONS

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*

NYODN DATE IN

Format: mm-dd-yyyy

*

NYODN DATE OUT

Format: mm-dd-yyyy

* NYODN TIME IN
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* NYODN TIME OUT
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*

HOSPITAL

Please also fill in the "other comment" field.
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HOSPITAL DATE IN

Format: mm-dd-yyyy

HOSPITAL DATE OUT

Format: mm-dd-yyyy

HOSPITAL TIME IN
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HOSPITAL TIME OUT
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RESEARCH

PLEASE SELECT WHICH ORGANS WERE PROCURED FOR RESEARCH
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PRESERVATIONIST
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HelpONLY SELECT THIS IF YOU PROCURED ORGANS FOR RESEARCH

COMMENTS & VALIDATION

COMMENTS AND OTHER NOTES
* SUBMITTED BY
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