20 Heart_Lung Transplant Recipient Follow Up 6 Month_Form.x

Data System for Organ Procurement and Transplantation Network

Heart_Lung Transplant Recipient Follow Up 6 Month_Form.xlsx

Heart/Lung Transplant Recipient Follow Up 6 Month (TRF)

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf












































Fields to be completed by members



























































































Form Section Field label Notes












































1-Recipient Information Organ Type 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 Last Name 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 HIC Display Only - Cascades from TCR












































1-Recipient Information Previous Follow-Up 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 DOB 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 State of Permanent Residence












































1-Recipient Information Zip Code












































2-Provider Information Recipient Center Type 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 Type 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 OPO Display Only - Cascades from feedback












































4-Patient Status Date: Last Seen, Retransplanted or Death












































4-Patient Status Patient Status












































4-Patient Status Primary Cause of Death












































4-Patient Status Primary Cause of Death//Specify












































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 Not required












































4-Patient Status Contributory Cause of Death//Specify Not required












































5-Clinical Information HIV Serology













































5-Clinical Information HIV NAT













































5-Clinical Information HbsAg













































5-Clinical Information HBV DNA













































5-Clinical Information HBV Core Antibody













































5-Clinical Information HCV Serology













































5-Clinical Information HCV NAT













































5-Clinical Information Heart Graft Status












































5-Clinical Information Heart Date of Graft Failure












































5-Clinical Information Heart Primary Cause of Graft Failure












































5-Clinical Information Heart Primary Cause of Graft Failure//Other, Specify












































5-Clinical Information Graft Status













































5-Clinical Information Date of Graft Failure













































5-Clinical Information Primary Cause of Graft Failure













































5-Clinical Information Primary Cause of Graft Failure// Other Specify












































5-Clinical Information Most Recent Anti-A Titer












































5-Clinical Information Most Recent Anti-A Titer//Sample Date












































5-Clinical Information Most Recent Anti-B Titer












































5-Clinical Information Most Recent Anti-B Titer//Sample Date






























































































Public Burden Statement












































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































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