43 Pancreas Transplant Recipient Follow Up Post 5 Year_Form

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
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
5-Clinical Information	Graft Status			4-Patient Status	Functional Status
5-Clinical Information	Most Recent Serum Creatinine			4-Patient Status at Time of Follow-Up	Cognitive Development
5-Clinical Information	Most Recent Serum Creatinine//Status	Value or status is reported, not both		4-Patient Status at Time of Follow-Up	Motor Development
5-Clinical Information	Date of Failure			5-Clinical Information	Date of Measurement
5-Clinical Information	Primary Cause of Graft Failure			5-Clinical Information	Height
5-Clinical Information	Primary Cause of Graft Failure//Other, Specify			5-Clinical Information	Height//Status	Value or status is reported, not both
5-Clinical Information	Graft/Vascular Thrombosis			5-Clinical Information	Height Percentile	Calculated for display only
5-Clinical Information	Infection			5-Clinical Information	Weight
5-Clinical Information	Bleeding			5-Clinical Information	Weight//Status	Value or status is reported, not both
5-Clinical Information	Anastomotic Leak			5-Clinical Information	Weight Percentile	Calculated for display only
5-Clinical Information	Acute Rejection			5-Clinical Information	BMI	Display Only - Cascades from Database
5-Clinical Information	Chronic Rejection			5-Clinical Information	BMI	Calculated for display only
5-Clinical Information	Biopsy Proven Isletitis			5-Clinical Information	Graft Status
5-Clinical Information	Pancreatitis			5-Clinical Information	Most Recent Serum Creatinine
5-Clinical Information	Patient Noncompliance			5-Clinical Information	Most Recent Serum Creatinine//Status	Value or status is reported, not both
5-Clinical Information	Contributory Cause of Graft Failure//Other, Specify			5-Clinical Information	Date of Failure
5-Clinical Information	Post Transplant Malignancy			5-Clinical Information	Primary Cause of Graft Failure
5-Clinical Information	Donor Related			5-Clinical Information	Primary Cause of Graft Failure//Other, Specify
5-Clinical Information	Recurrence of Pre-Tx Tumor			5-Clinical Information	Graft/Vascular Thrombosis
5-Clinical Information	De Novo Solid Tumor			5-Clinical Information	Infection
5-Clinical Information	De Novo Lymphoproliferative disease and Lymphoma			5-Clinical Information	Bleeding
				5-Clinical Information	Anastomotic Leak
	Public Burden Statement			5-Clinical Information	Acute Rejection
				5-Clinical Information	Chronic Rejection
				5-Clinical Information	Biopsy Proven Isletitis
				5-Clinical Information	Pancreatitis
				5-Clinical Information	Patient Noncompliance
				5-Clinical Information	Contributory Cause of Graft Failure//Other, Specify
				5-Clinical Information	Coronary Artery Disease Since Last Follow Up
				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
					Public Burden Statement