Document
Liver Transplant Recipient Registration (TRR)
ICR 201704-0915-007 · OMB 0915-0157 · Object 73071101.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | Liver Transplant Recipient Registration (TRR) |
| Author | Alex Garza |
| Last Modified By | Calc |
| File Modified | 2016-05-31 |
| File Created | 2026-07-14 |
| Conversion State | complete |
Extracted Text
TRR - Liver - Adults Fields to be completed by members Form Section 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 2 - Provider Information 2 - Provider Information 2 - Provider Information 2 - Provider Information 3 - Donor Information 3 - Donor Information 3 - Donor Information 4 - Patient Status 4 - Patient Status 4 - Patient Status 4 - Patient Status 4 - Patient Status 4 - Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 5- Pretransplant 5- Pretransplant Field Label Organ Recipient First Name Recipient Last Name Recipient Middle Initial SSN HIC DOB Gender Tx Date State of Permanent Residence Permanent Zip Recipient Center Code Recipient Center Type Surgeon Name NPI# UNOS Donor ID # Donor Type OPO Primary Diagnosis Primary Diagnosis//Specify Date: Last Seen, Retransplanted or Death Patient Status Primary Cause of Death Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Date of Admission to Tx Center Date of Discharge from Tx Center Patient on Life Support Ventilator Artificial Liver Other Mechanism Other Mechanism, Specify Functional Status Working for income Primary Source of Payment Primary Source of Payment, Specify Height Height in Centimeters//Status 5- Pretransplant 5- Pretransplant 5- Pretransplant Height Percentile//Growth Percentiles//%ile Weight Weight in Kilograms//Status 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant Weight Percentile//Growth Percentiles//%ile BMI BMI://%ile Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date 5- PreTransplant 5- PreTransplant 5- PreTransplant 6- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant HIV Serostatus NAT HIV CMV Status HBV Core Antibody HBV Surface Antibody Total HBV Core Antibody HBV Surface Antigen NAT HBV HCV Serostatus NAT HCV EBV Serostatus Has the recipient ever had a diagnosis of HCC? Multiple Organ Recipient Were extra vessels used in the transplant procedure Procedure Type Split Type Total Cold Ischemia Time (if pumped, include pump time) Total Cold Ischemia Time (if pumped, include pump time)://Status Previous Abdominal Surgery 6- PreTransplant 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 7- Post Transplant Portal Vein Thrombosis Transjugular Intrahepatic Portacaval Stint Shunt Pathology Conf. Liver Diag. of Hospital Discharge If Other Pathology Conf. Liver Diag. of Hospital Discharge//Specify 7- Post Transplant 7- Post Transplant 7- Post Transplant Graft Status Date of Graft Failure Primary Non-Function 7- Post Transplant Hepatic Artery Thrombosis 6-Transplant Procedure 7- Post Transplant 7- Post Transplant Other Vascular Thrombosis 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant Hepatic outflow obstruction Portal vein thrombosis Diffuse Cholangiopathy Hepatitis: DeNovo Hepatitis: Recurrent Recurrent Disease (non-Hepatitis) Acute Rejection Infection Other, Specify Did patient have any acute rejection episodes between transplant and discharge 7- Post Transplant Are any medications given currently for 9- Immunosupression Other maintenance or anti-rejection 9- Immunosupression Other immunosuppression medication 9- Immunosupression Other immunosuppression medication indication 9- Immunosupression Other days of induction Public Burden Statement dults by members Notes Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Not required Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from feedback Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from feedback Display Only - Cascades from feedback Display Only - Cascades from feedback Not required Not required Not required Not required Value or status is reported, not both Form Section 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 2 - Provider Information 2 - Provider Information 2 - Provider Information 2 - Provider Information 3 - Donor Information 3 - Donor Information 3 - Donor Information 4 - Patient Status 4 - Patient Status 4 - Patient Status 4 - Patient Status 4 - Patient Status 4 - Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status Calculated for display only Value or status is reported, not both 4-Patient Status 4-Patient Status 4-Patient Status Calculated for display only Display Only - Cascades from Database Calculated for display only Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from Database 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 6- PreTransplant 5- PreTransplant Display Only - Cascades from feedback Display Only - Cascades from feedback Display Only - Cascades from feedback 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant Value or status is reported, not both 6- PreTransplant 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 9- Immunosupression Other 9- Immunosupression Other 9- Immunosupression Other 9- Immunosupression Other TRR - Liver - Pediatrics Fields to be completed by members Field Label Organ Recipient First Name Recipient Last Name Recipient Middle Initial SSN HIC DOB Gender Tx Date State of Permanent Residence Permanent Zip Recipient Center Code Recipient Center Type Surgeon Name NPI# UNOS Donor ID # Donor Type OPO Primary Diagnosis Primary Diagnosis//Specify Date: Last Seen, Retransplanted or Death Patient Status Primary Cause of Death Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Date of Admission to Tx Center Date of Discharge from Tx Center Medical Condition at time of transplant Patient on Life Support Ventilator Artificial Liver Other Mechanism Other Mechanism, Specify Functional Status Working for income Academic Progress Academic Activity Level Primary Source of Payment Notes Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Not required Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from feedback Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from feedback Display Only - Cascades from feedback Display Only - Cascades from feedback Not required Not required Not required Not required Primary Source of Payment, Specify Cognitive Development Motor Development Date of Measurement Height Height in Centimeters//Status Value or status is reported, not both Height Percentile//Growth Percentiles//%ile Calculated for display only Weight Weight in Kilograms//Status Value or status is reported, not both Weight Percentile//Growth Percentiles//%ile BMI BMI://%ile Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date HIV Serostatus NAT HIV CMV Status HBV Core Antibody HBV Surface Antibody Total Calculated for display only Display Only - Cascades from Database Calculated for display only Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from Database HBV Core Antibody HBV Surface Antigen NAT HBV HCV Serostatus NAT HCV EBV Serostatus Has the recipient ever had a diagnosis of HCC? Multiple Organ Recipient Were extra vessels used in the transplant procedure Display Only - Cascades from feedback Display Only - Cascades from feedback Procedure Type Display Only - Cascades from feedback Split Type Total Cold Ischemia Time (if pumped, include pump time) Total Cold Ischemia Time (if pumped, include pump time)://Status Previous Abdominal Surgery Portal Vein Thrombosis Transjugular Intrahepatic Portacaval Stint Shunt Value or status is reported, not both Pathology Conf. Liver Diag. of Hospital Discharge If Other Pathology Conf. Liver Diag. of Hospital Discharge//Specify Graft Status Date of Graft Failure Primary Non-Function Hepatic Artery Thrombosis Other Vascular Thrombosis Hepatic outflow obstruction Portal vein thrombosis Diffuse Cholangiopathy Hepatitis: DeNovo Hepatitis: Recurrent Recurrent Disease (non-Hepatitis) Acute Rejection Infection Other, Specify Did patient have any acute rejection episodes between transplant and discharge Are any medications given currently for maintenance or anti-rejection immunosuppression medication immunosuppression medication indication days of induction Public Burden Statement