Form 3 Living Donor Follow Up_Form.xlsx

			Living Donor Follow Up (LDF)
			Fields to be completed by members
			Form Section	Field Label	Notes
				Urinalysis
			1-Provider Information	Recipient Center Code
			1-Provider Information	Recipient Center Code
			1-Provider Information	Recipient Center Type	Display Only - Cascades from Database
			1-Provider Information	Recipient Center Name
			1-Provider Information	Follow Up Code	Display Only - Cascades from Database
			1-Provider Information	Follow-Up Center Code	Display Only - Cascades from Database
			1-Provider Information	Follow-Up Center Type	Display Only - Cascades from Database
			1-Provider Information	Followup Center Code
			1-Provider Information	Followup Center Provider Number//Followup Center
			1-Provider Information	Followup Center Name//Followup Center
			2-Donor Information	Last Name	Display Only - Cascades from Database
			2-Donor Information	First Name	Display Only - Cascades from Database
			2-Donor Information	DOB	Display Only - Cascades from Database
			2-Donor Information	SSN	Display Only - Cascades from Database
			2-Donor Information	Gender	Display Only - Cascades from Database
			2-Donor Information	Donor ID	Display Only - Cascades from feedback
			2-Donor Information	Recovery Date	Display Only - Cascades from Database
			2-Donor Information	Organ(s) Recovered	Display Only - Cascades from Database
			3-Donor Status	Date of Initial Discharge	Display Only - Cascades from Database
			3-Donor Status	Most Recent Donor Status since//Date of last contact or death
			3-Donor Status	Most Recent Donor Status since
			3-Donor Status	Cause of Death
			3-Donor Status	Cause of Death//Specify
			3-Donor Status	Functional Status
			3-Donor Status	Physical Capacity
			3-Donor Status	Working for Income
			3-Donor Status	Working for Income//If No, Not Working Due To
			3-Donor Status	Working for Income//If Yes
				Donor Status//Attempts to Collect
			3-Donor Status	Loss of medical insurance due to donation
			3-Donor Status	Loss of health insurance
			3-Donor Status	Loss of life insurance
			4-Clinical Information	Date
			4-Clinical Information	Current weight
			4-Clinical Information	Weight in Lb
			4-Clinical Information	Weight //Status	Value or status is reported, not both
			4-Clinical Information	Height in Ft
			4-Clinical Information	Height in In
			4-Clinical Information	ER or urgent care visit related to donation since last follow-up
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	Total Bilirubin
			5-Liver Clinical Information	Total Bilirubin //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	SGOT/AST
			5-Liver Clinical Information	SGOT/AST //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	SGPT/ALT
			5-Liver Clinical Information	SGPT/ALT //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	Alkaline Phosphatase
			5-Liver Clinical Information	Alkaline Phosphatase //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	Serum Albumin
			5-Liver Clinical Information	Serum Albumin //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	Serum Creatinine
			5-Liver Clinical Information	Serum Creatinine //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	INR
			5-Liver Clinical Information	INR //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	Platelet Count
			5-Liver Clinical Information	Platelet Count//Status	Value or status is reported, not both
			6-Kidney Clinical Information	Date
			6-Kidney Clinical Information	Kidney//Serum Creatinine
			6-Kidney Clinical Information	Kidney Serum Creatinine //Status	Value or status is reported, not both
			6-Kidney Clinical Information	Date
			6-Kidney Clinical Information	Blood Pressure Systolic
			6-Kidney Clinical Information	Blood Pressure Systolic //Status	Value or status is reported, not both
			6-Kidney Clinical Information	Date
			6-Kidney Clinical Information	Blood Pressure Diastolic
			6-Kidney Clinical Information	Blood Pressure Diastolic //Status	Value or status is reported, not both
			6-Kidney Clinical Information	Donor Developed Hypertension Requiring Medication
			6-Kidney Clinical Information	Protein-Creatinine Ratio
			6-Kidney Clinical Information	Urine Protein
			6-Kidney Clinical Information	Maintenance Dialysis
			6-Kidney Clinical Information	Maintenance Dialysis//If Yes, Date First Dialyzed
			6-Kidney Clinical Information	Diabetes
			6-Kidney Clinical Information	Diabetes
			7-Lung Clinical Information	Activity Level
			7-Lung Clinical Information	Chronic Incisional Pain
			8-Complications	Has the donor been readmitted since
			8-Complications	If Yes, Date of First Readmission
			8-Complications	Date of First Readmission //Status	Value or status is reported, not both
			8-Complications	Specify Reason for First Readmission
			8-Complications	Complications since	Display Only - Cascades from Database
			8-Complications	Kidney Complications since	Display Only - Cascades from Database
			8-Complications	Kidney Complications Status//If Yes
			8-Complications	Kidney Complications//Specify
			8-Complications	Liver Complications since	Display Only - Cascades from Database
			8-Complications	Liver Complicatons Status//If Yes
			8-Complications	Liver Complications//Specify
			8-Complications	Complications//Specify
			9-Recipient Information	Recipient's Last Name	Display Only - Cascades from Database
			9-Recipient Information	Recipient's First Name	Display Only - Cascades from Database
			9-Recipient Information	Recipient's SSN	Display Only - Cascades from Database
			9-Recipient Information	Recipient's Name	Display Only - Cascades from Database
			9-Recipient Information	Transplant Date	Display Only - Cascades from Database
			PUBLIC BURDEN STATEMENT:
			The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0157 and it is valid until XX/XX/20XX. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].