41 Pancreas Transplant Recipient Registration_Form.xlsx

TRR - Pancreas - Adult
Fields to be completed by members					Fields to be completed by members
Form Section	Field Label	Notes		Form Section	Field Label	Notes
1- Recipient Information	Organ	Display Only - Cascades from TCR		1- Recipient Information	Organ	Display Only - Cascades from TCR
1- Recipient Information	Recipient First Name	Display Only - Cascades from TCR		1- Recipient Information	Recipient First Name	Display Only - Cascades from TCR
1- Recipient Information	Recipient Last Name	Display Only - Cascades from TCR		1- Recipient Information	Recipient Last Name	Display Only - Cascades from TCR
1- Recipient Information	Recipient Middle Initial	Not required		1- Recipient Information	Recipient Middle Initial	Not required
1- Recipient Information	SSN	Display Only - Cascades from TCR		1- Recipient Information	SSN	Display Only - Cascades from TCR
1- Recipient Information	HIC	Display Only - Cascades from TCR		1- Recipient Information	HIC	Display Only - Cascades from TCR
1- Recipient Information	DOB	Display Only - Cascades from TCR		1- Recipient Information	DOB	Display Only - Cascades from TCR
1- Recipient Information	Gender	Display Only - Cascades from TCR		1- Recipient Information	Gender	Display Only - Cascades from TCR
1- Recipient Information	Tx Date	Display Only - Cascades from feedback		1- Recipient Information	Tx Date	Display Only - Cascades from feedback
1- Recipient Information	State of Permanent Residence			1- Recipient Information	State of Permanent Residence
1- Recipient Information	Permanent Zip			1- Recipient Information	Permanent Zip
2- Provider Information	Recipient Center Code	Display Only - Cascades from TCR		2- Provider Information	Recipient Center Code	Display Only - Cascades from TCR
2- Provider Information	Recipient Center Type	Display Only - Cascades from TCR		2- Provider Information	Recipient Center Type	Display Only - Cascades from TCR
2- Provider Information	Surgeon Name			2- Provider Information	Surgeon Name
2- Provider Information	NPI#			2- Provider Information	NPI#
3- Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback		3- Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback
3- Donor Information	Donor Type	Display Only - Cascades from feedback		3- Donor Information	Donor Type	Display Only - Cascades from feedback
3- Donor Information	OPO	Display Only - Cascades from feedback		3- Donor Information	OPO	Display Only - Cascades from feedback
4- Patient Status	Primary Diagnosis			4- Patient Status	Primary Diagnosis
4- Patient Status	Primary Diagnosis//Specify			4- Patient Status	Primary Diagnosis//Specify
4- Patient Status	Date: Last Seen, Retransplanted or Death			4- Patient Status	Date: Last Seen, Retransplanted or Death
4- Patient Status	Patient Status			4- Patient Status	Patient Status
4- Patient Status	Primary Cause of Death			4- Patient Status	Primary Cause of Death
4- Patient Status	Cause of Death//Specify			4- Patient Status	Cause of Death//Specify
4- Patient Status	Contributory Cause of Death	Not required		4- Patient Status	Contributory Cause of Death	Not required
4- Patient Status	Contributory Cause of Death//Specify	Not required		4- Patient Status	Contributory Cause of Death//Specify	Not required
4- Patient Status	Contributory Cause of Death	Not required		4- Patient Status	Contributory Cause of Death	Not required
4- Patient Status	Contributory Cause of Death//Specify	Not required		4- Patient Status	Contributory Cause of Death//Specify	Not required
4- Patient Status	Date of Admission to Tx Center			4- Patient Status	Date of Admission to Tx Center
4- Patient Status	Date of Discharge from Tx Center			4- Patient Status	Date of Discharge from Tx Center
4- Patient Status	Functional Status			4- Patient Status	Functional Status
4- Patient Status	Working for income			4- Patient Status	Cognitive Development
4- Patient Status	Primary Source of Payment			4- Patient Status	Motor Development
4- Patient Status	Specify Foreign Government//Specify			4- Patient Status	Academic Progress
5- Pretransplant	Height			4- Patient Status	Academic Activity Level
5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both		4- Patient Status	Primary Source of Payment
5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		4- Patient Status	Specify Foreign Government//Specify
5- Pretransplant	Weight			5- Pretransplant	Date of Measurement
5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both		5- Pretransplant	Height
5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only		5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both
5- Pretransplant	BMI	Display Only - Cascades from Database		5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only
5- Pretransplant	BMI://%ile	Calculated for display only		5- Pretransplant	Weight
5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database		5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both
5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database		5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		5- Pretransplant	BMI	Display Only - Cascades from Database
5- PreTransplant	Pretransplant Dialysis			5- Pretransplant	BMI://%ile	Calculated for display only
5- PreTransplant	If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis			5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database
5- PreTransplant	If Yes, Date First Dialyzed//Status	Value or status is reported, not both		5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database
5- Pretransplant	Average Daily Insulin Units			5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
5- Pretransplant	Average Daily Insulin Units//Status	Value or status is reported, not both		5- PreTransplant	Pretransplant Dialysis
5- Pretransplant	Serum Creatinine at Time of Tx			5- PreTransplant	If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis
5- Pretransplant	Serum Creatinine at Time of Tx//Status	Value or status is reported, not both		5- PreTransplant	If Yes, Date First Dialyzed//Status	Value or status is reported, not both
5- PreTransplant	HIV Serostatus			5- Pretransplant	Average Daily Insulin Units
5- PreTransplant	NAT HIV			5- Pretransplant	Average Daily Insulin Units//Status	Value or status is reported, not both
5- PreTransplant	CMV Status			5- Pretransplant	Serum Creatinine at Time of Tx
5- PreTransplant	HBV Core Antibody			5- Pretransplant	Serum Creatinine at Time of Tx//Status	Value or status is reported, not both
5- PreTransplant	HBV Surface Antibody Total			5- Pretransplant	HIV Serostatus
5- PreTransplant	HBV Surface Antigen			5- PreTransplant	NAT HIV
5- PreTransplant	NAT HBV			5- Pretransplant	CMV Status
5- PreTransplant	HCV Serostatus			5- Pretransplant	HBV Core Antibody
5- PreTransplant	NAT HCV			5- Pretransplant	HBV Surface Antibody Total
5- PreTransplant	EBV Serostatus			5- Pretransplant	HBV Surface Antigen
5- PreTransplant	Malignancies between listing and transplant			5- PreTransplant	NAT HBV
5- PreTransplant	If yes, specify type			5- Pretransplant	HCV Serostatus
5- PreTransplant	Malignancies between listing and transplant//Specify			5- PreTransplant	NAT HCV
6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		5- Pretransplant	EBV Serostatus
6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback		5- Pretransplant	Malignancies between listing and transplant
6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		5- Pretransplant	Malignancies between listing and transplant//Specify
6-Transplant Procedure	Graft Placement			5- Pretransplant	If yes, specify type
6-Transplant Procedure	Operative Technique			6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
6-Transplant Procedure	Duct Management			6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
6-Transplant Procedure	Duct Management//Specify			6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
6-Transplant Procedure	Venous Vascular Management			6-Transplant Procedure	Graft Placement
6-Transplant Procedure	Arterial Reconstruction			6-Transplant Procedure	Operative Technique
6-Transplant Procedure	Arterial Reconstruction//Specify			6-Transplant Procedure	Duct Management
6-Transplant Procedure	Venous Extension Graft			6-Transplant Procedure	Duct Management//Specify
6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)			6-Transplant Procedure	Venous Vascular Management
6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)//Status	Value or status is reported, not both		6-Transplant Procedure	Arterial Reconstruction
7- PostTransplant	Pancreas Graft Status			6-Transplant Procedure	Arterial Reconstruction//Specify
7- PostTransplant	Patient using any method of blood sugar control?			6-Transplant Procedure	Venous Extension Graft
7- PostTransplant	Patient on insulin?	New field if pancreas graft status is functioning. Modified label if graft status is failed		6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)
7- PostTransplant	Date insulin resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed		6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)//Status	Value or status is reported, not both
7- PostTransplant	Total insulin dosage units			7- PostTransplant	Pancreas Graft Status
7- PostTransplant	Total insulin dosage units//ST	Value or status is reported, not both		7- PostTransplant	Patient using any method of blood sugar control?
7- PostTransplant	Insulin duration of use			7- PostTransplant	Patient on insulin?	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Insulin duration of use//ST	Value or status is reported, not both		7- PostTransplant	Date insulin resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Patient on oral medication to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed		7- PostTransplant	Total insulin dosage units
7- PostTransplant	Date oral medications resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed		7- PostTransplant	Total insulin dosage units//ST	Value or status is reported, not both
7- PostTransplant	Patient using diet to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed		7- PostTransplant	Insulin duration of use
7- PostTransplant	Date of Graft Failure			7- PostTransplant	Insulin duration of use//ST	Value or status is reported, not both
7- PostTransplant	C-Peptide Value			7- PostTransplant	Patient on oral medication to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	C-Peptide Value://ST=	Value or status is reported, not both		7- PostTransplant	Date oral medications resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Hba1c (%)			7- PostTransplant	Patient using diet to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Hba1c (%)//Status	Value or status is reported, not both		7- PostTransplant	Date of Graft Failure
7- PostTransplant	Pancreas Primary Cause of Graft Failure			7- PostTransplant	C-Peptide Value
7- PostTransplant	Pancreas Primary Cause of Graft Failure//Specify			7- PostTransplant	C-Peptide Value://ST=	Value or status is reported, not both
7- PostTransplant	Pancreas Graft/Vascular Thrombosis			7- PostTransplant	Hba1c (%)
7- PostTransplant	Pancreas Infection			7- PostTransplant	Hba1c (%)//Status	Value or status is reported, not both
7- PostTransplant	Bleeding			7- PostTransplant	Pancreas Primary Cause of Graft Failure
7- PostTransplant	Anastomotic Leak			7- PostTransplant	Pancreas Primary Cause of Graft Failure//Specify
7- PostTransplant	Hyperacute Rejection			7- PostTransplant	Pancreas Graft/Vascular Thrombosis
7- PostTransplant	Pancreas Acute Rejection			7- PostTransplant	Pancreas Infection
7- PostTransplant	Biopsy Proven Isletitis			7- PostTransplant	Bleeding
7- PostTransplant	Pancreatitis			7- PostTransplant	Anastomotic Leak
7- PostTransplant	Other, Specify			7- PostTransplant	Hyperacute Rejection
7- PostTransplant	Pancreatitis			7- PostTransplant	Pancreas Acute Rejection
7- PostTransplant	Anastomotic Leak			7- PostTransplant	Biopsy Proven Isletitis
7- PostTransplant	Abscess or Local Infection			7- PostTransplant	Pancreatitis
7- PostTransplant	Pancreas Transplant Complications: Other	Not required		7- PostTransplant	Other, Specify
7- PostTransplant	Did patient have any acute rejection episodes between transplant and discharge			7- PostTransplant	Pancreatitis
9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection			7- PostTransplant	Anastomotic Leak
9- Immunosupression Other	immunosuppression medication			7- PostTransplant	Abscess or Local Infection
9- Immunosupression Other	immunosuppression medication indication			7- PostTransplant	Pancreas Transplant Complications: Other	Not required
9- Immunosupression Other	days of induction			7- PostTransplant	Did patient have any acute rejection episodes between transplant and discharge
				9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection
	Public Burden Statement			9- Immunosupression Other	immunosuppression medication
				9- Immunosupression Other	immunosuppression medication indication
				9- Immunosupression Other	days of induction
					Public Burden Statement