Pancreas Transplant Candidate Registration_Form

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TCR - Pancreas - Adult
Fields to be completed by members
Form Section
1-Provider Information
1-Provider Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
3-Patient Status
3-Patient Status
3-Patient Status
3-Patient Status
3-Patient Status
3-Patient Status
4-Source of Payment
4-Source of Payment
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
6-General Medical Factors
6-General Medical Factors

Field Label
Transplant Center Code
Transplant Center Type://Recipient
Center
SSN:
Organ Registered:
Date of Listing or Add:
Last Name:
First Name:
Middle Initial://MI:
Previous Surname:
Gender:
HIC:
Date of Birth://DOB:
State of Permanent Residence:
Permanent ZIP Code:
Ethnicity/Race:
Citizenship:
Year of Entry to the U.S.
Year of Entry to the U.S Status//ST=
Country of Permanent Residence
Highest Education Level:
Functional Status:
Working for income:
Previous Transplant//Organ
Previous Transplant//Date
Previous Transplant//Graft Fail Date
Previous Pancreas Islet Infusion:
Source of Payment//Primary:
Foreign Government//Specify:
Height in cm://Height:
Height Status//ST=
Height Growth percentiles//%ile
Weight in kg://Weight:
Weight Status//ST=
Weight Growth percentiles//%ile
BMI:
BMI://%ile
ABO Blood Group:
Primary Diagnosis:
Primary Diagnosis//Specify:
Diabetes:
Patient on insulin?

6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors

6-General Medical Factors

If on insulin, enter the insulin date
Total insulin dosage units
Total insulin dosage units//ST=
Insulin duration of use:
Insulin duration of use://ST=
Symptomatic Peripheral Vascular
Disease:
Drug Treated COPD:
Any previous Malignancy:
Any previous Malignancy//Specify
Type:

6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
11-Kidney Medical Factors
11-Kidney Medical Factors

Any previous Malignancy//Specify:
Total Serum Albumin:
Total Serum Albumin//ST=
C-Peptide Value
C-Peptide Value://ST=
Hba1c (%):
Hba1c (%)://ST
Age of Diabetes Onset:
Age of Diabetes Onset//ST=

6-General Medical Factors
6-General Medical Factors
6-General Medical Factors

Public Burden Statement

Adult
by members

TCR - Pan
Fields to be co

Notes
Display Only - Cascades from Waitlist

Form Section
1-Provider Information

Display Only - Cascades from Waitlist
Display Only - Cascades from Waitlist
Display Only - Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist
Not required
Not required
Display Only - Cascades from Waitlist
Cascades from Waitlist
Not required
Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist

1-Provider Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
2-Candidate Information
3-Patient Status
3-Patient Status
3-Patient Status
3-Patient Status
3-Patient Status
3-Patient Status
3-Patient Status
3-Patient Status
4-Source of Payment
4-Source of Payment
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information
5-Clinical Information

Display Only - Cascades from Database
Display Only - Cascades from Database
Display Only - Cascades from Database

Display Only
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

Value or status is reported, not both
Value or status is reported, not both

5-Clinical Information
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors

Value or status is reported, not both
Value or status is reported, not both
Value or status is reported, not both
Value or status is reported, not both

6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
6-General Medical Factors
11-Kidney Medical Factors
11-Kidney Medical Factors

TCR - Pancreas - Pediatric
Fields to be completed by members
Field Label
Transplant Center Code
Transplant Center Type://Recipient
Center
Organ Registered:
Date of Listing or Add:
Last Name:
First Name:
Middle Initial://MI:
Previous Surname:
SSN:
Gender:
HIC:
Date of Birth://DOB:
State of Permanent Residence:
Permanent ZIP Code:
Ethnicity/Race:
Citizenship:
Year of Entry to the U.S.
Year of Entry to the U.S Status//ST=
Country of Permanent Residence
Highest Education Level:
Functional Status:
Cognitive Development:
Motor Development:
Academic Progress:
Academic Activity Level:
Previous Transplant//Organ
Previous Transplant//Date
Previous Transplant//Graft Fail Date
Source of Payment//Primary:
Foreign Government//Specify:
Date of Measurement:
Height in cm://Height:
Height Status//ST=
Height Growth percentiles//%ile
Weight in kg://Weight:
Weight Status//ST=
Weight Growth percentiles//%ile
BMI:
BMI://%ile
ABO Blood Group:
Primary Diagnosis:

Notes
Display Only - Cascades from Waitlist
Display Only - Cascades from Waitlist
Display Only - Cascades from Waitlist
Display Only - Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist
Not required
Not required
Display Only - Cascades from Waitlist
Cascades from Waitlist
Not required
Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist

Display Only - Cascades from Database
Display Only - Cascades from Database
Display Only - Cascades from Database

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 Waitlist

Primary Diagnosis//Specify:
Diabetes:
Patient on insulin?
If on insulin, enter the insulin date
Total insulin dosage units
Total insulin dosage units//ST=
Insulin duration of use:
Insulin duration of use://ST=
Any previous Malignancy:
Any previous Malignancy//Specify
Type:
Any previous Malignancy//Specify:
Total Serum Albumin:
Total Serum Albumin//ST=
C-Peptide Value
C-Peptide Value://ST=
Hba1c (%):
Hba1c (%)://ST
Age of Diabetes Onset:
Age of Diabetes Onset//ST=
Public Burden Statement

Value or status is reported, not both
Value or status is reported, not both

Value or status is reported, not both
Value or status is reported, not both
Value or status is reported, not both
Value or status is reported, not both