Document
Intestine Transplant Recipient Registration_Form
ICR 201906-0915-001 · OMB 0915-0157 · Object 92114401.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | Intestine Transplant Recipient Registration_Form |
| Author | Alex Garza |
| Last Modified By | Calc |
| File Modified | 2016-05-31 |
| File Created | 2026-10-04 |
| Conversion State | complete |
Extracted Text
TRR - Intestine - Adult Fields to be completed by members Form Section 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 2 - Provider Information 2 - Provider Information 2 - Provider Information 2 - Provider Information 3 - Donor Information 3 - Donor Information 3 - Donor Information 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status Field Label Organ Recipient First Name Recipient Last Name Recipient Middle Initial SSN HIC DOB Gender Tx Date State of Permanent Residence Permanent Zip Recipient Center Code Recipient Center Type Surgeon Name NPI# UNOS Donor ID # Donor Type OPO Primary Diagnosis Primary Diagnosis//Specify Secondary Diagnosis Secondary Diagnosis//Specify Date: Last Seen, Retransplanted or Death Patient Status Primary Cause of Death Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Date of Admission to Tx Center Date of Discharge from Tx Center Medical Condition at time of transplant Patient on Life Support Ventilator Artificial Liver Other Mechanism Other Mechanism, Specify Functional Status Working for income Primary Source of Payment Primary Source of Payment, Specify 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5-Pretransplant 5-Pretransplant 5-Pretransplant 5-Pretransplant 5-Pretransplant 5-Pretransplant 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure Height Height in Centimeters//Status Height Percentile//Growth Percentiles//%ile Weight Weight Percentile//Growth in Kilograms//Status Weight Percentiles//%ile BMI BMI://%ile Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date HIV Serostatus NAT HIV CMV Status HBV Core Antibody HBV Surface Antibody Total HBV Surface Antigen NAT HBV HCV Serostatus NAT HCV EBV Serostatus Total Bilirubin Total Bilirubin//Status Serum Albumin Serum Albumin//Status Serum Creatinine Serum Creatinine//Status Multiple Organ Recipient Intestine Venous Drainage Native Viscera Venous Drainage Procedure Type Stomach 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 7- Post Transplant 7- Post Transplant 7- Post Transplant Small Intestine Duodenum LargeIschemic Intestine Time (include cold, warm Total and anastomotic time)Hours (include cold, Total ischemia Time warm and anastomotic time)//Status Recent Septicemia Exhausted Vascular Access Previous Abdominal Surgery Dilated/Non-Functional Bowel Segments Other risk factors Graft Status TPN Dependent IV Dependent 7- Post Transplant 7- Post Transplant Oral Feeding Tube Feed 7- Post Transplant 7- Post Transplant 7- Post Transplant 7 - PostTransplant 10- Immunosupression Other 9- Immunosupression Other Date of Graft Failure Primary Cause of Graft Failure Primary Cause Graft Failure//Specify Did patient haveofany acute rejection episodes between transplant and discharge Are any medications given currently for maintenance or anti-rejection immunosuppression medication 9- Immunosupression Other 9- Immunosupression Other immunosuppression medication indication days of induction Public Burden Statement Adult y members Notes Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Not required Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only -- Cascades Cascades from from TCR Display Only feedback Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from feedback Display Only - Cascades from feedback Display Only - Cascades from feedback Not required Not required Not required Not required Not required Not required Not required Form Section 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 1- Recipient Information 2 - Provider Information 2 - Provider Information 2 - Provider Information 2 - Provider Information 3 - Donor Information 3 - Donor Information 3 - Donor Information 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status 4-Patient Status Value or status is reported, not both Calculated for display only Value or status is reported, not both Calculated for-display only Display Only Cascades from Database Calculated for-display only Display Only Cascades from Database Display Only - Cascades from Database Display Only - Cascades from Database Value or status is reported, not both Value or status is reported, not both Value status- Cascades is reported, not both DisplayorOnly from feedback Display Only - Cascades from feedback Value or status is reported, not both Not required 4-Patient Status 4-Patient Status 4-Patient Status 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- Pretransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5- PreTransplant 5-Pretransplant 5-Pretransplant 5-Pretransplant 5-Pretransplant 5-Pretransplant 5-Pretransplant 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 6-Transplant Procedure 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7- Post Transplant 7 - PostTransplant 10- Immunosupression Other 9- Immunosupression Other 9- Immunosupression Other 9- Immunosupression Other TRR - Intestine - Pediatric Fields to be completed by members Field Label Organ Recipient First Name Recipient Last Name Recipient Middle Initial SSN HIC DOB Gender Tx Date State of Permanent Residence Permanent Zip Recipient Center Code Recipient Center Type Surgeon Name NPI# UNOS Donor ID # Donor Type OPO Primary Diagnosis Primary Diagnosis//Specify Secondary Diagnosis Secondary Diagnosis//Specify Date: Last Seen, Retransplanted or Death Patient Status Primary Cause of Death Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Date of Admission to Tx Center Date of Discharge from Tx Center Medical Condition at time of transplant Patient on Life Support Ventilator Artificial Liver Other Mechanism Other Mechanism, Specify Functional Status Academic Progress Academic Activity Level Primary Source of Payment Notes Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Not required Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from feedback Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from feedback Display Only - Cascades from feedback Display Only - Cascades from feedback Not required Not required Not required Not required Not required Not required Not required Primary Source of Payment, Specify Cognitive Development Motor Development Date of Measurement Height Height Percentile//Growth in Centimeters//Status Value or status is reported, not both Height Percentiles//%ile Calculated for display only Weight Weight in Kilograms//Status Value or status is reported, not both Weight Percentile//Growth Percentiles//%ile Calculated for display only BMI Display Only - Cascades from Database BMI://%ile Calculated for display only Previous Transplant Organ Display Only - Cascades from Database Previous Transplant Date Display Only - Cascades from Database Previous Transplant Graft Fail Date Display Only - Cascades from Database HIV Serostatus NAT HIV CMV Status HBV Core Antibody HBV Surface Antibody Total HBV Surface Antigen NAT HBV HCV Serostatus NAT HCV EBV Serostatus Total Bilirubin Total Bilirubin//Status Value or status is reported, not both Serum Albumin Serum Albumin//Status Value or status is reported, not both Serum Creatinine Serum Creatinine//Status Value or status is reported, not both Multiple Organ Recipient Display Only - Cascades from feedback Were extra vessels used in the transplant procedure Display Only - Cascades from feedback Intestine Venous Drainage Native Viscera Venous Drainage Procedure Type Display Only - Cascades from feedback Stomach Small Intestine Duodenum Large Intestine Time (include cold, warm Total Ischemic and time)Hours (include cold, Totalanastomotic ischemia Time warm and anastomotic time)//Status Value or status is reported, not both Recent Septicemia Exhausted Vascular Access Previous Abdominal Surgery Dilated/Non-Functional Bowel Segments Other risk factors Not required Graft Status TPN Dependent IV Dependent Oral Feeding Tube Feed Date of Graft Failure Primary Cause of Graft Failure Primary Cause Graft Failure//Specify Did patient haveofany acute rejection episodes between transplant and discharge Are any medications given currently for maintenance or anti-rejection immunosuppression medication immunosuppression medication indication days of induction Public Burden Statement mbers