19 Heart_Lung Transplant Recipient Registration_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Heart_Lung Transplant Recipient Registration_Form.xlsx

Heart/Lung Recipient Registration

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRR - Heart/Lung - 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 Physician Name
2-Provider Information Physician Name
2-Provider Information Physician NPI#
2-Provider Information Physician NPI#
2-Provider Information Surgeon Name
2-Provider Information Surgeon Name
2-Provider Information Surgeon NPI#
2-Provider Information Surgeon NPI#
3-DonorInformation UNOS Donor ID # Display Only - Cascades from TCR
3-DonorInformation UNOS Donor ID # Display Only - Cascades from TCR
3-DonorInformation Donor Type Display Only - Cascades from feedback
3-DonorInformation Donor Type Display Only - Cascades from feedback
3-DonorInformation OPO Display Only - Cascades from feedback
3-DonorInformation 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 Medical Condition at time of transplant
4-Patient Status Medical Condition at time of transplant
4-Patient Status Patient on Life Support
4-Patient Status Patient on Life Support
4-Patient Status Extra Corporeal Membrane Oxygenation
4-Patient Status Extra Corporeal Membrane Oxygenation
4-Patient Status Intra Aortic Balloon Pump
4-Patient Status Intra Aortic Balloon Pump
4-Patient Status Other Mechanism
4-Patient Status Prostaglandins
4-Patient Status Other Mechanism, Specify
4-Patient Status Intravenous Inotropes
4-Patient Status Prostacyclin Infusion
4-Patient Status Ventilator
4-Patient Status Prostacyclin Inhalation
4-Patient Status Inhaled NO
4-Patient Status Patient on Ventricular Assist Device
4-Patient Status Other Mechanism
4-Patient Status Life Support: VAD Brand1
4-Patient Status Other Mechanism, Specify
4-Patient Status Life Support: VAD Brand1//Specify
4-Patient Status Prostacyclin Infusion
4-Patient Status Life Support: VAD Brand2
4-Patient Status Prostacyclin Inhalation
4-Patient Status Life Support: VAD Brand2//Specify
4-Patient Status Patient on Ventricular Assist Device
4-Patient Status Functional Status
4-Patient Status Life Support: VAD Brand1
4-Patient Status Working for income
4-Patient Status Life Support: VAD Brand1//Specify
4-Patient Status Primary Source of Payment
4-Patient Status Life Support: VAD Brand2
4-Patient Status Primary Source of Payment, Specify
4-Patient Status Life Support: VAD Brand2//Specify
5- Pretransplant Height
4-Patient Status Functional Status
5- Pretransplant Height in Centimeters//Status Value or status is reported, not both
4-Patient Status Academic Progress
5- Pretransplant Height Percentile//Growth Percentiles//%ile Calculated for display only
4-Patient Status Academic Activity Level
5- Pretransplant Weight
4-Patient Status Primary Source of Payment
5- Pretransplant Weight in Kilograms//Status Value or status is reported, not both
4-Patient Status Primary Source of Payment, Specify
5- Pretransplant Weight Percentile//Growth Percentiles//%ile Calculated for display only
4-Patient Status Cognitive Development
5- Pretransplant BMI Display Only - Cascades from Database
4-Patient Status Motor Development
5- Pretransplant BMI://%ile Calculated for display only
5- Pretransplant Date of Measurement
5- Pretransplant Previous Transplant Organ Display Only - Cascades from Database
5- Pretransplant Height
5- Pretransplant Previous Transplant Date Display Only - Cascades from Database
5- Pretransplant Height in Centimeters//Status Value or status is reported, not both
5- Pretransplant Previous Transplant Graft Fail Date Display Only - Cascades from Database
5- Pretransplant Height Percentile//Growth Percentiles//%ile Calculated for display only
5- PreTransplant HIV Serostatus
5- Pretransplant Weight
5- PreTransplant NAT HIV

5- Pretransplant Weight in Kilograms//Status Value or status is reported, not both
5- PreTransplant CMV Status

5- Pretransplant Weight Percentile//Growth Percentiles//%ile Calculated for display only
6- PreTransplant HBV Core Antibody
5- Pretransplant BMI Display Only - Cascades from Database
5- PreTransplant HBV Surface Antibody Total

5- Pretransplant BMI://%ile Calculated for display only
5- PreTransplant HBV Surface Antigen
5- Pretransplant Previous Transplant Organ Display Only - Cascades from Database
5- PreTransplant NAT HBV

5- Pretransplant Previous Transplant Date Display Only - Cascades from Database
5- PreTransplant HCV Serostatus
5- Pretransplant Previous Transplant Graft Fail Date Display Only - Cascades from Database
5- PreTransplant NAT HCV

5- PreTransplant HIV Serostatus
5- PreTransplant EBV Serostatus
5- PreTransplant NAT HIV
5-Pretransplant PA (sys)mm/Hg
5- PreTransplant CMV Status
5-Pretransplant PA (sys)mm/Hg//Status Value or status is reported, not both
6- PreTransplant HBV Core Antibody
5-Pretransplant PA(sys)mm/Hg Inotropes/VASODilators
5- PreTransplant HBV Surface Antibody Total
5-Pretransplant PA(dia) mm/Hg
5- PreTransplant HBV Surface Antigen
5-Pretransplant PA(dia) mm/HG//Status Value or status is reported, not both
5- PreTransplant NAT HBV
5-Pretransplant PA (dia) mm/Hg Inotropes/Vasodilators
5- PreTransplant HCV Serostatus
5-Pretransplant PA(mean) mm/Hg
5- PreTransplant NAT HCV
5-Pretransplant PA(mean) mm/Hg//Status Value or status is reported, not both
5- PreTransplant EBV Serostatus
5-Pretransplant PA (mean) mm/Hg Inotropes/Vasodilators
5-Pretransplant PA (sys)mm/Hg
5-Pretransplant PCW(mean) mm/Hg
5-Pretransplant PA (sys)mm/Hg//Status Value or status is reported, not both
5-Pretransplant PCW(mean) mm/Hg//Status Value or status is reported, not both
5-Pretransplant PA(sys)mm/Hg Inotropes/VASODilators
5-Pretransplant PCW (mean) mm/Hg Inotropes/Vasodilators
5-Pretransplant PA(dia) mm/Hg
5-Pretransplant CO L/min
5-Pretransplant PA(dia) mm/HG//Status Value or status is reported, not both
5-Pretransplant CO L/min//Status Value or status is reported, not both
5-Pretransplant PA (dia) mm/Hg Inotropes/Vasodilators
5-Pretransplant CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators
5-Pretransplant PA(mean) mm/Hg
5-Pretransplant Most Recent Serum Creatinine
5-Pretransplant PA(mean) mm/Hg//Status Value or status is reported, not both
5-Pretransplant Most Recent Serum Creatinine//Status Value or status is reported, not both
5-Pretransplant PA (mean) mm/Hg Inotropes/Vasodilators
5-Pretransplant Most Recent Total Bilirubin
5-Pretransplant PCW(mean) mm/Hg
5-Pretransplant Most Recent Total Bilirubin//Status Value or status is reported, not both
5-Pretransplant PCW(mean) mm/Hg//Status Value or status is reported, not both
5-Pretransplant Chronic Steroid Use
5-Pretransplant PCW (mean) mm/Hg Inotropes/Vasodilators
5-Pretransplant FVC
5-Pretransplant CO L/min
5-Pretransplant FVC % predicted//Status Value or status is reported, not both
5-Pretransplant CO L/min//Status Value or status is reported, not both
5-Pretransplant FeV1
5-Pretransplant CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators
5-Pretransplant FeV1 % predicted//Status Value or status is reported, not both
5- Pretransplant Cardiac Index Display Only - Cascades from Database
5-Pretransplant pCO2
5-Pretransplant Most Recent Serum Creatinine
5-Pretransplant pCO2 mm/Hg//Status Value or status is reported, not both
5-Pretransplant Most Recent Serum Creatinine//Status Value or status is reported, not both
5-Pretransplant Transfusions
5-Pretransplant Most Recent Total Bilirubin
5-Pretransplant Infection Requiring IV Therapy within 2 wks prior to Tx
5-Pretransplant Most Recent Total Bilirubin//Status Value or status is reported, not both
5-Pretransplant Dialysis
5-Pretransplant Chronic Steroid Use
5-Pretransplant Prior Cardiac Surgery (non-transplant)
5-Pretransplant FVC
5-Pretransplant If yes, check all that apply
5-Pretransplant FVC % predicted//Status Value or status is reported, not both
5-Pretransplant Prior Cardiac Surgery//Specify
5-Pretransplant FeV1
5-Pretransplant Prior Lung Surgery (non-transplant)
5-Pretransplant FeV1 % predicted//Status Value or status is reported, not both
5-Pretransplant If yes, check all that apply
5-Pretransplant pCO2
5-Pretransplant Prior Lung Surgery//Specify
5-Pretransplant pCO2 mm/Hg//Status Value or status is reported, not both
5-Pretransplant Episode of Ventilatory Support
5-Pretransplant Transfusions
5-Pretransplant If yes, indicate most recent timeframe
5-Pretransplant Infection Requiring IV Therapy within 2 wks prior to Tx
5-Pretransplant Tracheostomy
5-Pretransplant Dialysis
6-Transplant Procedure Multiple Organ Recipient Display Only - Cascades from feedback
5-Pretransplant Episode of Ventilatory Support
6-Transplant Procedure Were extra vessels used in the transplant procedure Display Only - Cascades from feedback
5-Pretransplant If yes, indicate most recent timeframe
6-Transplant Procedure Procedure Type Display Only - Cascades from feedback
5-Pretransplant Tracheostomy
6-Transplant Procedure Heart Procedure
5-Pretransplant Prior Thoracic Surgery other than prior transplant
6-Transplant Procedure Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Heart, Heart-Lung
5-Pretransplant If yes, number of prior sternotomies
6-Transplant Procedure Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time)://Status Value or status is reported, not both
5-Pretransplant If yes, number of prior thoracotomies
6-Transplant Procedure Lung(s) perfused prior to transplant?

5-Pretransplant Prior congenital cardiac surgery
6-Transplant Procedure Perfusion occurred at:

5-Pretransplant If yes, palliative surgery
6-Transplant Procedure Perfusion performed by:

5-Pretransplant If yes, corrective surgery
6-Transplant Procedure Total time on perfusion

5-Pretransplant If yes, single ventricular physiology
6-Transplant Procedure Lung(s) received at transplant center

5-Pretransplant Most Recent Anti-A Titer
6-Transplant Procedure On ice

5-Pretransplant Most Recent Anti-A Titer//Sample Date
6-Transplant Procedure On pump

5-Pretransplant Most Recent Anti-B Titer
6-Transplant Procedure Right Lung/Enbloc:
Stayed on pump
Put on ice

Left Lung:
Stayed on pump
Put on ice


5-Pretransplant Most Recent Anti-B Titer//Sample Date
7-Post Transplant Graft Status

6-Transplant Procedure Multiple Organ Recipient Display Only - Cascades from feedback
7-Post Transplant Date of Graft Failure

6-Transplant Procedure Were extra vessels used in the transplant procedure Display Only - Cascades from feedback
7-Post Transplant Primary Cause of Graft Failure

6-Transplant Procedure Procedure Type Display Only - Cascades from feedback
7-Post Transplant Primary Cause of Graft Failure// Other Specify
6-Transplant Procedure Heart Procedure
7 - PostTransplant Stroke
6-Transplant Procedure Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Heart, Heart-Lung
7 - PostTransplant Dialysis
6-Transplant Procedure Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time)://Status Value or status is reported, not both
7- Post Transplant Ventilator Support
6-Transplant Procedure Lung(s) perfused prior to transplant?
7- Post Transplant Reintubated
6-Transplant Procedure Perfusion occurred at:
7 - PostTransplant Permanent Pacemaker
6-Transplant Procedure Perfusion performed by:
7 - PostTransplant Airway Dehiscence
6-Transplant Procedure Total time on perfusion
7- Post Transplant Did patient have any acute rejection episodes between transplant and discharge
6-Transplant Procedure Lung(s) received at transplant center
7- Post Transplant Intubated at 72 hours

6-Transplant Procedure On ice
7- Post Transplant PaO2 at 72 hours

6-Transplant Procedure On pump
7- Post Transplant PaO2 at 72 hours//Status Value or status is reported, not both
6-Transplant Procedure Right Lung/Enbloc:
Stayed on pump
Put on ice

Left Lung:
Stayed on pump
Put on ice

7- Post Transplant FiO2 at 72 hours

7- Post Transplant Graft Status
7- Post Transplant FiO2 at 72 hours//Status Value or status is reported, not both
7- Post Transplant Date of Graft Failure
7- Post Transplant ECMO a 72 hours

7- Post Transplant Primary Cause of Graft Failure
7- Post Transplant Inhaled NO at 72 hours

7- Post Transplant Primary Cause of Graft Failure// Other Specify
9- Immunosupression Other Are any medications given currently for maintenance or anti-rejection
7- Post Transplant Ventilator Support
9- Immunosupression Other immunosuppression medication

7- Post Transplant Reintubated
9- Immunosupression Other immunosuppression medication indication

7 - Post Transplant Permanent Pacemaker
9- Immunosupression Other days of induction

7 - Post Transplant Airway Dehiscence




7- Post Transplant Did patient have any acute rejection episodes between transplant and discharge

Public Burden Statement

7- Post Transplant Intubated at 72 hours




7- Post Transplant PaO2 at 72 hours




7- Post Transplant PaO2 at 72 hours//Status Value or status is reported, not both




7- Post Transplant FiO2 at 72 hours




7- Post Transplant FiO2 at 72 hours//Status Value or status is reported, not both




7- Post Transplant ECMO a 72 hours




7- Post Transplant Inhaled NO at 72 hours




7- Post Transplant Most Recent Anti-A Titer




7- Post Transplant Most Recent Anti-A Titer//Sample Date




7- Post Transplant Most Recent Anti-B Titer




7- Post Transplant Most Recent Anti-B Titer//Sample Date




8 - PostTransplant Stroke




9- Immunosupression Other Are any medications given currently for maintenance or anti-rejection




9- Immunosupression Other immunosuppression medication




9- Immunosupression Other immunosuppression medication indication




9- Immunosupression Other days of induction












Public Burden Statement
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy