24 Liver Transplant Candidate Registration_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Liver Transplant Candidate Registration_Form.xlsx

Liver Transplant Candidate Registration (TCR)

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TCR - Liver - Adult
TCR - Liver - Pediatric
Fields to be completed by members Fields to be completed by members







Form Section Field Label Notes
Form Section Field Label Notes
1-Provider Information Transplant Center Code Display Only - Cascades from Waitlist
1-Provider Information Transplant Center Code Display Only - Cascades from Waitlist
1-Provider Information Transplant Center Type://Recipient Center Display Only - Cascades from Waitlist
1-Provider Information Transplant Center Type://Recipient Center Display Only - Cascades from Waitlist
2-Candidate Information Organ Registered: Display Only - Cascades from Waitlist
2-Candidate Information Organ Registered: Display Only - Cascades from Waitlist
2-Candidate Information Date of Listing or Add: Display Only - Cascades from Waitlist
2-Candidate Information Date of Listing or Add: Display Only - Cascades from Waitlist
2-Candidate Information Last Name: Cascades from Waitlist
2-Candidate Information Last Name: Cascades from Waitlist
2-Candidate Information First Name: Cascades from Waitlist
2-Candidate Information First Name: Cascades from Waitlist
2-Candidate Information Middle Initial://MI: Not required
2-Candidate Information Middle Initial://MI: Not required
2-Candidate Information Previous Surname: Not required
2-Candidate Information Previous Surname: Not required
2-Candidate Information SSN: Display Only - Cascades from Waitlist
2-Candidate Information SSN: Display Only - Cascades from Waitlist
2-Candidate Information Gender: Cascades from Waitlist
2-Candidate Information Gender: Cascades from Waitlist
2-Candidate Information HIC: Not required
2-Candidate Information HIC: Not required
2-Candidate Information Date of Birth://DOB: Cascades from Waitlist
2-Candidate Information Date of Birth://DOB: Cascades from Waitlist
2-Candidate Information State of Permanent Residence: Cascades from Waitlist
2-Candidate Information State of Permanent Residence: Cascades from Waitlist
2-Candidate Information Permanent ZIP Code: Cascades from Waitlist
2-Candidate Information Permanent ZIP Code: Cascades from Waitlist
2-Candidate Information Ethnicity/Race: Cascades from Waitlist
2-Candidate Information Ethnicity/Race: Cascades from Waitlist
2-Candidate Information Citizenship:

2-Candidate Information Citizenship:
2-Candidate Information Year of Entry to the U.S.

2-Candidate Information Year of Entry to the U.S.
2-Candidate Information Year of Entry to the U.S Status//ST=

2-Candidate Information Year of Entry to the U.S Status//ST=
2-Candidate Information Country of Permanent Residence

2-Candidate Information Country of Permanent Residence
2-Candidate Information Highest Education Level:

2-Candidate Information Highest Education Level:
3-Patient Status Patient on Life Support:

3-Patient Status Patient on Life Support:
3-Patient Status Life Support://Ventilator

3-Patient Status Life Support://Ventilator
3-Patient Status Life Support://Artifical Liver

3-Patient Status Life Support://Artifical Liver
3-Patient Status Life Support://Other Mechanism, Specify

3-Patient Status Life Support://Other Mechanism, Specify
3-Patient Status Life Support:Other Mechanism//Specify:

3-Patient Status Life Support:Other Mechanism//Specify:
3-Patient Status Functional Status:

3-Patient Status Functional Status:
3-Patient Status Working for income:

3-Patient Status Cognitive Development:
3-Patient Status Previous Transplant//Organ Display Only - Cascades from Database
3-Patient Status Motor Development:
3-Patient Status Previous Transplant//Date Display Only - Cascades from Database
3-Patient Status Academic Progress:
3-Patient Status Previous Transplant//Graft Fail Date Display Only - Cascades from Database
3-Patient Status Academic Activity Level:
3-Patient Status Previous Pancreas Islet Infusion:

3-Patient Status Previous Transplant//Organ Display Only - Cascades from Database
4-Source of Payment Source of Payment//Primary:

3-Patient Status Previous Transplant//Date Display Only - Cascades from Database
4-Source of Payment Foreign Government//Specify:

3-Patient Status Previous Transplant//Graft Fail Date Display Only - Cascades from Database
5-Clinical Information Height in cm://Height:

4-Source of Payment Source of Payment//Primary:
5-Clinical Information Height Status//ST= Value or status is reported, not both
4-Source of Payment Foreign Government//Specify:
5-Clinical Information Height Growth percentiles//%ile Calculated for display only
5-Clinical Information Date of Measurement:
5-Clinical Information Weight in kg://Weight:
5-Clinical Information Height in cm://Height:
5-Clinical Information Weight Status//ST= Value or status is reported, not both
5-Clinical Information Height Status//ST= Value or status is reported, not both
5-Clinical Information Weight Growth percentiles//%ile Calculated for display only
5-Clinical Information Height Growth percentiles//%ile Calculated for display only
5-Clinical Information BMI: Display Only - Cascades from Database
5-Clinical Information Weight in kg://Weight:
5-Clinical Information BMI://%ile Calculated for display only
5-Clinical Information Weight Status//ST= Value or status is reported, not both
5-Clinical Information ABO Blood Group: Display Only - Cascades from Waitlist
5-Clinical Information Weight Growth percentiles//%ile Calculated for display only
5-Clinical Information Primary Diagnosis:

5-Clinical Information BMI: Display Only - Cascades from Database
5-Clinical Information Primary Diagnosis//Specify:

5-Clinical Information BMI://%ile Calculated for display only
5-Clinical Information Secondary Diagnosis: Not required
5-Clinical Information ABO Blood Group: Display Only - Cascades from Waitlist
5-Clinical Information Secondary Diagnosis//Specify:

5-Clinical Information Primary Diagnosis:
6-General Medical Factors Diabetes:

5-Clinical Information Primary Diagnosis//Specify:
6-General Medical Factors Any previous Malignancy:

5-Clinical Information Secondary Diagnosis: Not required
6-General Medical Factors Any previous Malignancy//Specify Type:

5-Clinical Information Secondary Diagnosis//Specify:
6-General Medical Factors Cholagiocarcinoma//Neoadjuvant Therapy

6-General Medical Factors Diabetes:
6-General Medical Factors Any previous Malignancy//Specify:

6-General Medical Factors Any previous Malignancy:
5-Clinical Information Has the candidate ever had a diagnosis of HCC?

6-General Medical Factors Any previous Malignancy//Specify Type:
7-Liver Medical Factors Previous Upper Abdominal Surgery:

6-General Medical Factors Cholagiocarcinoma//Neoadjuvant Therapy
7-Liver Medical Factors Spontaneous Bacterial Peritonitis:

6-General Medical Factors Any previous Malignancy//Specify:
7-Liver Medical Factors History of Portal Vein Thrombosis:

6-General Medical Factors Has the candidate ever had a diagnosis of HCC?
7-Liver Medical Factors History of TIPSS:

7-Liver Medical Factors Previous Upper Abdominal Surgery:




7-Liver Medical Factors Spontaneous Bacterial Peritonitis:

Public Burden Statement

7-Liver Medical Factors History of Portal Vein Thrombosis:




7-Liver Medical Factors History of TIPSS:












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

© 2024 OMB.report | Privacy Policy