31 Intestine Transplant Recipient Registration_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Intestine Transplant Recipient Registration_Form.xlsx

Intestine Transplant Recipient Registration (TRR)

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRR - Intestine - 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 Secondary Diagnosis Not required
4-Patient Status Secondary Diagnosis Not required
4-Patient Status Secondary Diagnosis//Specify Not required
4-Patient Status Secondary Diagnosis//Specify Not required
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 Not required
4-Patient Status Date of Discharge from Tx Center Not required
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 Ventilator
4-Patient Status Ventilator
4-Patient Status Artificial Liver
4-Patient Status Artificial Liver
4-Patient Status Other Mechanism
4-Patient Status Other Mechanism
4-Patient Status Other Mechanism, Specify
4-Patient Status Other Mechanism, Specify
4-Patient Status Functional Status
4-Patient Status Functional Status
4-Patient Status Working for income
4-Patient Status Academic Progress
4-Patient Status Primary Source of Payment
4-Patient Status Academic Activity Level
4-Patient Status Primary Source of Payment, Specify
4-Patient Status Primary Source of Payment
5- Pretransplant Height
4-Patient Status Primary Source of Payment, Specify
5- Pretransplant Height in Centimeters//Status Value or status is reported, not both
4-Patient Status Cognitive Development
5- Pretransplant Height Percentile//Growth Percentiles//%ile Calculated for display only
4-Patient Status Motor Development
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 HIV Serostatus
5- Pretransplant BMI://%ile Calculated for display only
5- PreTransplant NAT HIV

5- Pretransplant Previous Transplant Organ Display Only - Cascades from Database
5- PreTransplant CMV Status

5- Pretransplant Previous Transplant Date Display Only - Cascades from Database
5- PreTransplant HBV Core Antibody
5- Pretransplant Previous Transplant Graft Fail Date Display Only - Cascades from Database
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 Total Bilirubin
5- PreTransplant NAT HBV
5-Pretransplant Total Bilirubin//Status Value or status is reported, not both
5- PreTransplant HCV Serostatus
5-Pretransplant Serum Albumin
5- PreTransplant NAT HCV
5-Pretransplant Serum Albumin//Status Value or status is reported, not both
5- PreTransplant EBV Serostatus
5-Pretransplant Serum Creatinine
5-Pretransplant Total Bilirubin
5-Pretransplant Serum Creatinine//Status Value or status is reported, not both
5-Pretransplant Total Bilirubin//Status Value or status is reported, not both
6-Transplant Procedure Multiple Organ Recipient Display Only - Cascades from feedback
5-Pretransplant Serum Albumin
6-Transplant Procedure Intestine Venous Drainage
5-Pretransplant Serum Albumin//Status Value or status is reported, not both
6-Transplant Procedure Native Viscera Venous Drainage
5-Pretransplant Serum Creatinine
6-Transplant Procedure Procedure Type Display Only - Cascades from feedback
5-Pretransplant Serum Creatinine//Status Value or status is reported, not both
6-Transplant Procedure Stomach
6-Transplant Procedure Multiple Organ Recipient Display Only - Cascades from feedback
6-Transplant Procedure Small Intestine
6-Transplant Procedure Were extra vessels used in the transplant procedure Display Only - Cascades from feedback
6-Transplant Procedure Duodenum
6-Transplant Procedure Intestine Venous Drainage
6-Transplant Procedure Large Intestine
6-Transplant Procedure Native Viscera Venous Drainage
6-Transplant Procedure Total Ischemic Time (include cold, warm and anastomotic time)
6-Transplant Procedure Procedure Type Display Only - Cascades from feedback
6-Transplant Procedure Total ischemia Time Hours (include cold, warm and anastomotic time)//Status Value or status is reported, not both
6-Transplant Procedure Stomach
6-Transplant Procedure Recent Septicemia
6-Transplant Procedure Small Intestine
6-Transplant Procedure Exhausted Vascular Access
6-Transplant Procedure Duodenum
6-Transplant Procedure Previous Abdominal Surgery
6-Transplant Procedure Large Intestine
6-Transplant Procedure Dilated/Non-Functional Bowel Segments
6-Transplant Procedure Total Ischemic Time (include cold, warm and anastomotic time)
6-Transplant Procedure Other risk factors Not required
6-Transplant Procedure Total ischemia Time Hours (include cold, warm and anastomotic time)//Status Value or status is reported, not both
7- Post Transplant Graft Status
6-Transplant Procedure Recent Septicemia
7- Post Transplant TPN Dependent
6-Transplant Procedure Exhausted Vascular Access
7- Post Transplant IV Dependent
6-Transplant Procedure Previous Abdominal Surgery
7- Post Transplant Oral Feeding
6-Transplant Procedure Dilated/Non-Functional Bowel Segments
7- Post Transplant Tube Feed
6-Transplant Procedure Other risk factors Not required
7- Post Transplant Date of Graft Failure
7- Post Transplant Graft Status
7- Post Transplant Primary Cause of Graft Failure
7- Post Transplant TPN Dependent
7- Post Transplant Primary Cause of Graft Failure//Specify
7- Post Transplant IV Dependent
7 - PostTransplant Did patient have any acute rejection episodes between transplant and discharge
7- Post Transplant Oral Feeding
10- Immunosupression Other Are any medications given currently for maintenance or anti-rejection
7- Post Transplant Tube Feed
9- Immunosupression Other immunosuppression medication

7- Post Transplant Date of Graft Failure
9- Immunosupression Other immunosuppression medication indication

7- Post Transplant Primary Cause of Graft Failure
9- Immunosupression Other days of induction

7- Post Transplant Primary Cause of Graft Failure//Specify




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

Public Burden Statement

10- 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
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