42 Pancreas Transplant Recipient Follow Up 6 Month-5 Year_F

TRF - Pancreas - 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 Type	Display Only - Cascades from Database		1-Recipient Information	Organ Type	Display Only - Cascades from Database
1-Recipient Information	Follow up code	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 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	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	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	Previous Follow-Up	Display Only - Cascades from prior TRF		1-Recipient Information	Previous Follow-Up	Display Only - Cascades from prior TRF
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 Database		1-Recipient Information	Tx Date	Display Only - Cascades from Database
1-Recipient Information	Previous Px Stat Date	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	Transplant Discharge Date
1-Recipient Information	State of Permanent Residence			1-Recipient Information	State of Permanent Residence
1-Recipient Information	Zip Code			1-Recipient Information	Zip Code
2-Provider Information	Recipient Center	Display Only - Cascades from TCR		2-Provider Information	Recipient Center	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	Followup Center Code	Display Only - Cascades from Database		2-Provider Information	Followup Center Code	Display Only - Cascades from Database
2-Provider Information	Followup Center Type	Display Only - Cascades from Database		2-Provider Information	Followup Center Type	Display Only - Cascades from Database
2-Provider Information	Physician Name			2-Provider Information	Physician Name
2-Provider Information	NPI#			2-Provider Information	NPI#
2-Provider Information	Follow-up Care Provided By			2-Provider Information	Follow-up Care Provided By
2-Provider Information	Follow-up Care Provided By//Specify			2-Provider Information	Follow-up Care Provided By//Specify
3-Donor Information	UNOS Donor ID #	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	Donor Type	Display Only - Cascades from Database
3-Donor Information	OPO	Display Only - Cascades from feedback		3-Donor Information	OPO	Display Only - Cascades from feedback
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	Primary Cause of Death//Specify			4-Patient Status	Primary 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	Has the patient been hospitalized since the last patient status date			4-Patient Status	Has the patient been hospitalized since the last patient status date
4-Patient Status	Functional Status			4-Patient Status	Functional Status
4-Patient Status	Working for income			4-Patient Status at Time of Follow-Up	Cognitive Development
4-Patient Status	Primary Insurance at Follow-up			4-Patient Status at Time of Follow-Up	Motor Development
4-Patient Status	Primary Source of Payment, Specify			4-Patient Status	Working for income
5-Clinical Information	Weight			4-Patient Status	Academic Progress
5-Clinical Information	Weight//Status	Value or status is reported, not both		4-Patient Status	Academic Activity Level
5-Clinical Information	HIV Serology			4-Patient Status	Primary Insurance at Follow-up
5-Clinical Information	HIV NAT			5-Clinical Information	Date of Measurement
5-Clinical Information	HbsAg			5-Clinical Information	Height
5-Clinical Information	HBV DNA			5-Clinical Information	Height//Status	Value or status is reported, not both
5-Clinical Information	HBV Core Antibody			5-Clinical Information	Height Percentile	Calculated for display only
5-Clinical Information	HCV Serology			5-Clinical Information	Weight
5-Clinical Information	HCV NAT			5-Clinical Information	Weight//Status	Value or status is reported, not both
5-Clinical Information	Graft Status			5-Clinical Information	Weight Percentile	Calculated for display only
5-Clinical Information	Patient using any method of blood sugar control?			5-Clinical Information	BMI	Display Only - Cascades from Database
5-Clinical Information	Patient on insulin?	New field if pancreas graft status is functioning. Modification to current label if graft status is failed.		5-Clinical Information	BMI	Calculated for display only
5-Clinical Information	Date insulin resumed	New field if pancreas graft status is functioning. Modification to current label if graft status is failed.		5-Clinical Information	HIV Serology
5-Clinical Information	Total insulin dosage units			5-Clinical Information	HIV NAT
5-Clinical Information	Total insulin dosage units//ST	Value or status is reported, not both		5-Clinical Information	HbsAg
5-Clinical Information	Insulin duration of use			5-Clinical Information	HBV DNA
5-Clinical Information	Insulin duration of use//ST	Value or status is reported, not both		5-Clinical Information	HBV Core Antibody
5-Clinical Information	Patient on oral medication to control blood sugar	New field if pancreas graft status is functioning. Modification to current label if graft status is failed.		5-Clinical Information	HCV Serology
5-Clinical Information	Date oral medications resumed	New field if pancreas graft status is functioning. Modification to current label if graft status is failed.		5-Clinical Information	HCV NAT
5-Clinical Information	Patient using diet to control blood sugar	New field if pancreas graft status is functioning. Modification to current label if graft status is failed.		5-Clinical Information	Graft Status
5-Clinical Information	Date of Graft Failure			5-Clinical Information	Patient using any method of blood sugar control?
5-Clinical Information	C-Peptide Value			5-Clinical Information	Patient on insulin?	New field if pancreas graft status is functioning. Modification to current label if graft status is failed.
5-Clinical Information	C-Peptide Value://ST=	Value or status is reported, not both		5-Clinical Information	Date insulin resumed	New field if pancreas graft status is functioning. Modification to current label if graft status is failed.
5-Clinical Information	Hba1c (%)			5-Clinical Information	Total insulin dosage units
5-Clinical Information	Hba1c (%)//Status	Value or status is reported, not both		5-Clinical Information	Total insulin dosage units//ST	Value or status is reported, not both
5-Clinical Information	Primary Cause of Graft Failure			5-Clinical Information	Insulin duration of use
5-Clinical Information	Primary Cause of Graft Failure//Other, Specify			5-Clinical Information	Insulin duration of use//ST	Value or status is reported, not both
5-Clinical Information	Graft/Vascular Thrombosis			5-Clinical Information	Patient on oral medication to control blood sugar	New field if pancreas graft status is functioning. Modification to current label if graft status is failed.
5-Clinical Information	Infection			5-Clinical Information	Date oral medications resumed	New field if pancreas graft status is functioning. Modification to current label if graft status is failed.
5-Clinical Information	Bleeding			5-Clinical Information	Patient using diet to control blood sugar	New field if pancreas graft status is functioning. Modification to current label if graft status is failed.
5-Clinical Information	Anastomotic Leak			5-Clinical Information	Date of Graft Failure
5-Clinical Information	Acute Rejection			5-Clinical Information	C-Peptide Value
5-Clinical Information	Chronic Rejection			5-Clinical Information	C-Peptide Value://ST=	Value or status is reported, not both
5-Clinical Information	Biopsy Proven Isletitis			5-Clinical Information	Hba1c (%)
5-Clinical Information	Pancreatitis			5-Clinical Information	Hba1c (%)//Status	Value or status is reported, not both
5-Clinical Information	Patient Noncompliance			5-Clinical Information	Primary Cause of Graft Failure
5-Clinical Information	Contributory Cause of Graft Failure//Other, Specify			5-Clinical Information	Primary Cause of Graft Failure//Other, Specify
5-Clinical Information	Conv. From Bladder to Enteric Drain Performed			5-Clinical Information	Graft/Vascular Thrombosis
5-Clinical Information	If Yes, Enteric Drainage Date			5-Clinical Information	Infection
5-Clinical Information	Most Recent Serum Creatinine			5-Clinical Information	Bleeding
5-Clinical Information	Most Recent Serum Creatinine//Status	Value or status is reported, not both		5-Clinical Information	Anastomotic Leak
5-Clinical Information	Pancreas Transplant Complications (Not leading to graft failure)	Display Only - Cascades from Database		5-Clinical Information	Acute Rejection
5-Clinical Information	Pancreatitis			5-Clinical Information	Chronic Rejection
5-Clinical Information	Anastomotic Leak			5-Clinical Information	Biopsy Proven Isletitis
5-Clinical Information	Abscess or Local Infection			5-Clinical Information	Pancreatitis
5-Clinical Information	Other Complications			5-Clinical Information	Patient Noncompliance
5-Clinical Information	Did patient have any acute rejection episodes during the follow-up period			5-Clinical Information	Contributory Cause of Graft Failure//Other, Specify
5-Clinical Information	Post Transplant Malignancy			5-Clinical Information	Conv. From Bladder to Enteric Drain Performed
5-Clinical Information	Donor Related			5-Clinical Information	If Yes, Enteric Drainage Date
5-Clinical Information	Recurrence of Pre-Tx Tumor			5-Clinical Information	Most Recent Serum Creatinine
5-Clinical Information	De Novo Solid Tumor			5-Clinical Information	Most Recent Serum Creatinine//Status	Value or status is reported, not both
5-Clinical Information	De Novo Lymphoproliferative disease and Lymphoma			5-Clinical Information	Pancreas Transplant Complications (Not leading to graft failure)	Display Only - Cascades from Database
7-Immunosuppressive Information	Were any medications given during the follow-up period for maintenance			5-Clinical Information	Pancreatitis
7-Immunosuppressive Information	Previous Validated Maintenance Follow-Up Medications	Display Only - Cascades from Database		5-Clinical Information	Anastomotic Leak
7-Immunosuppressive Information	Immunosuppression medication			5-Clinical Information	Abscess or Local Infection
7-Immunosuppressive Information	Immunosuppression medication indication			5-Clinical Information	Other Complications
				5-Clinical Information	Did patient have any acute rejection episodes during the follow-up period
	Public Burden Statement			5-Clinical Information	Post Transplant Malignancy
				5-Clinical Information	Donor Related
				5-Clinical Information	Recurrence of Pre-Tx Tumor
				5-Clinical Information	De Novo Solid Tumor
				5-Clinical Information	De Novo Lymphoproliferative disease and Lymphoma
				7-Immunosuppressive Information	Were any medications given during the follow-up period for maintenance
				7-Immunosuppressive Information	Previous Validated Maintenance Follow-Up Medications	Display Only - Cascades from Database
				7-Immunosuppressive Information	Immunosuppression medication
				7-Immunosuppressive Information	Immunosuppression medication indication
					Public Burden Statement