10 Heart Transplant Recipient Follow Up Post 5 Year_Form.xl
Data System for Organ Procurement and Transplantation Network
Heart Transplant Recipient Follow Up Post 5 Year_Form.xlsx
Heart Transplant Recipient Follow Up Post 5 Year
OMB: 0915-0157
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0157 can be found here:
Document [xlsx]
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TRF (Post 5-Year) - Heart - Adult 
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| 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 Type | Display Only - Cascades from Database | 1-Recipient Information | Organ Type | Display Only - Cascades from Database | |||||||||||||||||
| 1-Recipient Information | Follow up code | Display Only - Cascades from Database | 1-Recipient Information | Follow up code | Display Only - Cascades from Database | |||||||||||||||||
| 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 | Display Only - Cascades from TCR | 1-Recipient Information | Recipient Middle Initial | Display Only - Cascades from TCR | |||||||||||||||||
| 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 | Previous Follow-Up | Display Only - Cascades from prior TRF | 1-Recipient Information | Previous Follow-Up | Display Only - Cascades from prior TRF | |||||||||||||||||
| 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 Database | 1-Recipient Information | Tx Date | Display Only - Cascades from Database | |||||||||||||||||
| 1-Recipient Information | Previous Px Stat Date | Display Only - Cascades from prior TRF | 1-Recipient Information | Previous Px Stat Date | Display Only - Cascades from prior TRF | |||||||||||||||||
| 1-Recipient Information | Transplant Discharge Date | 1-Recipient Information | Transplant Discharge Date | |||||||||||||||||||
| 1-Recipient Information | State of Permanent Residence | 1-Recipient Information | State of Permanent Residence | |||||||||||||||||||
| 1-Recipient Information | Zip Code | 1-Recipient Information | Zip Code | |||||||||||||||||||
| 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 | Recipient Center | Display Only - Cascades from TCR | 2-Provider Information | Recipient Center | Display Only - Cascades from TCR | |||||||||||||||||
| 2-Provider Information | Followup Center Code | Display Only - Cascades from Database | 2-Provider Information | Followup Center Code | Display Only - Cascades from Database | |||||||||||||||||
| 2-Provider Information | Followup Center Type | Display Only - Cascades from Database | 2-Provider Information | Followup Center Type | Display Only - Cascades from Database | |||||||||||||||||
| 3- Donor Information | UNOS Donor ID # | Display Only - Cascades from Database | 3- Donor Information | UNOS Donor ID # | Display Only - Cascades from Database | |||||||||||||||||
| 3- Donor Information | Donor Type | Display Only - Cascades from Database | 3- Donor Information | Donor Type | Display Only - Cascades from Database | |||||||||||||||||
| 3 - Donor Information | OPO | Display Only - Cascades from feedback | 3- Donor Information | OPO | Display Only - Cascades from feedback | |||||||||||||||||
| 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 | Primary Cause of Death//Specify | 4-Patient Status | Primary Cause of Death//Specify | |||||||||||||||||||
| 5-Clinical Information | Heart Graft Status | 4-Patient Status | Functional Status | |||||||||||||||||||
| 5-Clinical Information | Heart Date of Graft Failure | 4-Patient Status at Time of Follow-Up | Cognitive Development | |||||||||||||||||||
| 5-Clinical Information | Heart Primary Cause of Graft Failure | 4-Patient Status at Time of Follow-Up | Motor Development | |||||||||||||||||||
| 5-Clinical Information | Heart Primary Cause of Graft Failure//Other, Specify | 5-Clinical Information | Date of Measurement | |||||||||||||||||||
| 5-Clinical Information | Chronic Dialysis | 5-Clinical Information | Height | |||||||||||||||||||
| 5-Clinical Information | Renal Tx since Thoracic Tx | 5-Clinical Information | Height//Status | Value or status is reported, not both | ||||||||||||||||||
| 5-Clinical Information | Most Recent Serum Creatinine | 5-Clinical Information | Height Percentile | Calculated for display only | ||||||||||||||||||
| 5-Clinical Information | Most Recent Serum Creatinine//Status | Value or status is reported, not both | 5-Clinical Information | Weight | ||||||||||||||||||
| 5-Clinical Information | Post Transplant Malignancy | 5-Clinical Information | Weight//Status | Value or status is reported, not both | ||||||||||||||||||
| 5-Clinical Information | Donor Related | 5-Clinical Information | Weight Percentile | Calculated for display only | ||||||||||||||||||
| 5-Clinical Information | Recurrence of Pre-Tx Tumor | 5-Clinical Information | BMI | Display Only - Cascades from Database | ||||||||||||||||||
| 5-Clinical Information | De Novo Solid Tumor | 5-Clinical Information | BMI | Calculated for display only | ||||||||||||||||||
| 5-Clinical Information | De Novo Lymphoproliferative disease and Lymphoma | 5-Clinical Information | Heart Graft Status | |||||||||||||||||||
| 5-Clinical Information | Other, Specify | 5-Clinical Information | Heart Date of Graft Failure | |||||||||||||||||||
| 5-Clinical Information | Heart Primary Cause of Graft Failure | |||||||||||||||||||||
| Public Burden Statement | 5-Clinical Information | Heart Primary Cause of Graft Failure//Other, Specify | ||||||||||||||||||||
| 5-Clinical Information | Coronary Artery Disease Since Last Follow Up | |||||||||||||||||||||
| 5-Clinical Information | Chronic Dialysis | |||||||||||||||||||||
| 5-Clinical Information | Renal Tx since Thoracic Tx | |||||||||||||||||||||
| 5-Clinical Information | Most Recent Serum Creatinine | |||||||||||||||||||||
| 5-Clinical Information | Most Recent Serum Creatinine//Status | |||||||||||||||||||||
| 5-Clinical Information | New diabetes onset between last follow-up to the current follow-up | |||||||||||||||||||||
| 5-Clinical Information | Diabetes: If Yes, Insulin Dependent | |||||||||||||||||||||
| 5-Clinical Information | Post Transplant Malignancy | |||||||||||||||||||||
| 5-Clinical Information | Donor Related | |||||||||||||||||||||
| 5-Clinical Information | Recurrence of Pre-Tx Tumor | |||||||||||||||||||||
| 5-Clinical Information | De Novo Solid Tumor | |||||||||||||||||||||
| 5-Clinical Information | De Novo Lymphoproliferative disease and Lymphoma | |||||||||||||||||||||
| Public Burden Statement | ||||||||||||||||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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