40 Pancreas Transplant Candidate Registration_Form.xlsx

TCR - Pancreas - Adult				TCR - Pancreas - 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	SSN:	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:	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:	Not required		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:	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	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:	Display Only		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:			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
6-General Medical Factors	Diabetes:			5-Clinical Information	ABO Blood Group:	Display Only - Cascades from Waitlist
6-General Medical Factors	Patient on insulin?			5-Clinical Information	Primary Diagnosis:
6-General Medical Factors	If on insulin, enter the insulin date			5-Clinical Information	Primary Diagnosis//Specify:
6-General Medical Factors	Total insulin dosage units			6-General Medical Factors	Diabetes:
6-General Medical Factors	Total insulin dosage units//ST=	Value or status is reported, not both		6-General Medical Factors	Patient on insulin?
6-General Medical Factors	Insulin duration of use:			6-General Medical Factors	If on insulin, enter the insulin date
6-General Medical Factors	Insulin duration of use://ST=	Value or status is reported, not both		6-General Medical Factors	Total insulin dosage units
6-General Medical Factors	Symptomatic Peripheral Vascular Disease:			6-General Medical Factors	Total insulin dosage units//ST=	Value or status is reported, not both
6-General Medical Factors	Drug Treated COPD:			6-General Medical Factors	Insulin duration of use:
6-General Medical Factors	Any previous Malignancy:			6-General Medical Factors	Insulin duration of use://ST=	Value or status is reported, not both
6-General Medical Factors	Any previous Malignancy//Specify Type:			6-General Medical Factors	Any previous Malignancy:
6-General Medical Factors	Any previous Malignancy//Specify:			6-General Medical Factors	Any previous Malignancy//Specify Type:
6-General Medical Factors	Total Serum Albumin:			6-General Medical Factors	Any previous Malignancy//Specify:
6-General Medical Factors	Total Serum Albumin//ST=	Value or status is reported, not both		6-General Medical Factors	Total Serum Albumin:
6-General Medical Factors	C-Peptide Value			6-General Medical Factors	Total Serum Albumin//ST=	Value or status is reported, not both
6-General Medical Factors	C-Peptide Value://ST=	Value or status is reported, not both		6-General Medical Factors	C-Peptide Value
6-General Medical Factors	Hba1c (%):			6-General Medical Factors	C-Peptide Value://ST=	Value or status is reported, not both
6-General Medical Factors	Hba1c (%)://ST	Value or status is reported, not both		6-General Medical Factors	Hba1c (%):
11-Kidney Medical Factors	Age of Diabetes Onset:			6-General Medical Factors	Hba1c (%)://ST	Value or status is reported, not both
11-Kidney Medical Factors	Age of Diabetes Onset//ST=	Value or status is reported, not both		11-Kidney Medical Factors	Age of Diabetes Onset:
				11-Kidney Medical Factors	Age of Diabetes Onset//ST=	Value or status is reported, not both
	Public Burden Statement
					Public Burden Statement