6 Heart Transplant Candidate Registration_Form.xlsx

TCR - Heart - Adult
Fields to be completed by members						Fields to be completed by members
Form Section	Field Label	Notes		Form Section	Field Label	Notes
1-Provider Information	Transplant Center Code	Display Only - Cascades from Waitlist		2-Provider Information(1)	Transplant Center Code	Display Only - Cascades from Waitlist
1-Provider Information	Transplant Center Type://Recipient Center	Display Only - Cascades from Waitlist		1-Provider Information(2)	Transplant Center Type://Recipient Center	Display Only - Cascades from Waitlist
2-Candidate Information	Organ Registered:	Display Only - Cascades from Waitlist		2-Candidate Information(2)	Organ Registered:	Display Only - Cascades from Waitlist
2-Candidate Information	Date of Listing or Add:	Display Only - Cascades from Waitlist		2-Candidate Information(3)	Date of Listing or Add:	Display Only - Cascades from Waitlist
2-Candidate Information	Last Name:	Cascades from Waitlist		2-Candidate Information(4)	Last Name:	Cascades from Waitlist
2-Candidate Information	First Name:	Cascades from Waitlist		2-Candidate Information(5)	First Name:	Cascades from Waitlist
2-Candidate Information	Middle Initial://MI:	Not required		2-Candidate Information(6)	Middle Initial://MI:	Not required
2-Candidate Information	Previous Surname:	Not required		2-Candidate Information(11)	Previous Surname:	Not required
2-Candidate Information	SSN:	Display Only - Cascades from Waitlist		2-Candidate Information(1 & 8)	SSN:	Display Only - Cascades from Waitlist
2-Candidate Information	Gender:	Cascades from Waitlist		2-Candidate Information(10)	Gender:	Cascades from Waitlist
2-Candidate Information	HIC:	Not required		2-Candidate Information(8)	HIC:	Not required
2-Candidate Information	Date of Birth://DOB:	Cascades from Waitlist		2-Candidate Information(9)	Date of Birth://DOB:	Cascades from Waitlist
2-Candidate Information	State of Permanent Residence:	Cascades from Waitlist		2-Candidate Information(12)	State of Permanent Residence:	Cascades from Waitlist
2-Candidate Information	Permanent ZIP Code:	Cascades from Waitlist		2-Candidate Information(13)	Permanent ZIP Code:	Cascades from Waitlist
2-Candidate Information	Ethnicity/Race:	Cascades from Waitlist		2-Candidate Information(16)	Ethnicity/Race:	Cascades from Waitlist
2-Candidate Information	Citizenship:			2-Candidate Information(17)	Citizenship:
2-Candidate Information	Year of Entry to the U.S.			2-Candidate Information(19)	Year of Entry to the U.S.
2-Candidate Information	Year of Entry to the U.S Status//ST=			2-Candidate Information(18)	Year of Entry to the U.S Status//ST=
2-Candidate Information	Country of Permanent Residence			2-Candidate Information(18)	Country of Permanent Residence
2-Candidate Information	Highest Education Level:			2-Candidate Information(19)	Highest Education Level:
3-Patient Status	Patient on Life Support:			3-Patient Status(2)	Patient on Life Support:
3-Patient Status	Life Support://Extra Corporeal Membrane Oxygenation			3-Patient Status(3)	Life Support://Extra Corporeal Membrane Oxygenation
3-Patient Status	Life Support://Intra Aortic Balloon Pump			3-Patient Status(4)	Life Support://Intra Aortic Balloon Pump
3-Patient Status	Life Support://Prostaglandins			3-Patient Status(5)	Life Support://Prostaglandins
3-Patient Status	Life Support://Intravenous Inotropes			3-Patient Status(6)	Life Support://Intravenous Inotropes
3-Patient Status	Life Support://Inhaled NO			3-Patient Status(7)	Life Support://Inhaled NO
3-Patient Status	Life Support://Ventilator			3-Patient Status(7)	Life Support://Ventilator
3-Patient Status	Life Support://Other Mechanism, Specify			3-Patient Statu(8)	Life Support://Other Mechanism, Specify
3-Patient Status	Life Support:Other Mechanism//Specify:			3-Patient Status(9)	Life Support:Other Mechanism//Specify:
3-Patient Status	Life Support://Patient on Ventricular Assist Device:			3 -Patient Status(26)	Life Support://Patient on Ventricular Assist Device:
3-Patient Status	Life Support://VAD Brand1:			3 -Patient Status(27)	Life Support://VAD Brand1:
3-Patient Status	Life Support://VAD Brand2:			3 -Patient Status(28)	Life Support://VAD Brand2:
3-Patient Status	Life Support:VAD Brand1//Specify:			3 -Patient Status(29)	Life Support:VAD Brand1//Specify:
3-Patient Status	Life Support:VAD Brand2//Specify:			3 -Patient Status(29)	Life Support:VAD Brand2//Specify:
3-Patient Status	Functional Status:			3-Patient Status(11)	Functional Status:
3-Patient Status	Working for income:			3-Patient Status(12)	Cognitive Development:
3-Patient Status	Previous Transplant//Organ	Display Only - Cascades from Database		3-Patient Status(12)	Motor Development:
3-Patient Status	Previous Transplant//Date	Display Only - Cascades from Database		3-Patient Status(13)	Working for income:
3-Patient Status	Previous Transplant//Graft Fail Date	Display Only - Cascades from Database		3-Patient Status(16)	Academic Progress:
3-Patient Status	Previous Pancreas Islet Infusion			3-Patient_Status (17)	Academic Activity Level:
4-Source of Payment	Source of Payment//Primary:				Previous Transplant//Organ	Display Only - Cascades from Database
4-Source of Payment	Foreign Government//Specify:				Previous Transplant//Date	Display Only - Cascades from Database
5-Clinical Information	Height in cm://Height:				Previous Transplant//Graft Fail Date	Display Only - Cascades from Database
5-Clinical Information	Height Status//ST=	Value or status is reported, not both		4-Source of Payment(1)	Source of Payment//Primary:
5-Clinical Information	Height Growth percentiles//%ile	Calculated for display only		4-Source of Payment(2)	Foreign Government//Specify:
5-Clinical Information	Weight in kg://Weight:			5-Clinical Information(1)	Date of Measurement:
5-Clinical Information	Weight Status//ST=	Value or status is reported, not both		5-Clinical Information(1)	Height in cm://Height:
5-Clinical Information	Weight Growth percentiles//%ile	Calculated for display only		5-Clinical Information(2)	Height Status//ST=	Value or status is reported, not both
5-Clinical Information	BMI:	Display Only - Cascades from Database		5-Clinical Information(2)	Height Growth percentiles//%ile	Calculated for display only
5-Clinical Information	BMI://%ile	Calculated for display only		5-Clinical Information(3)	Weight in kg://Weight:
5-Clinical Information	ABO Blood Group:	Display Only - Cascades from Waitlist		5-Clinical Information(4)	Weight Status//ST=	Value or status is reported, not both
5-Clinical Information	Primary Diagnosis:			5-Clinical Information	Weight Growth percentiles//%ile	Calculated for display only
5-Clinical Information	Primary Diagnosis//Specify:			5-Clinical Information(5)	BMI:	Display Only - Cascades from Database
6-General Medical Factors	Diabetes:			5-Clinical Information(4)	BMI://%ile	Calculated for display only
6-General Medical Factors	Dialysis:			5-Clinical Information(5)	ABO Blood Group:	Display Only - Cascades for Waitlist
6-General Medical Factors	Symptomatic Cerebrovascular Disease:			5-Clinical Information(7)	Primary Diagnosis:
6-General Medical Factors	Any previous Malignancy:			5-Clinical Information(8)	Primary Diagnosis//Specify:
6-General Medical Factors	Any previous Malignancy//Specify Type:			6-General Medical Factors(1)	Diabetes:
6-General Medical Factors	Any previous Malignancy//Specify:			6-General Medical Factors(2)	Dialysis:
6-General Medical Factors	Most Recent Serum Creatinine:			6-General Medical Factors(6)	Symptomatic Cerebrovascular Disease:
6-General Medical Factors	Most Recent Serum Creatinine//ST=	Value or status is reported, not both		6-General Medical Factors	Any previous Malignancy:
7-Heart Medical Factors	Implantable Defibrillator:			6-General Medical Factors(14)	Any previous Malignancy//Specify Type:
7-Heart Medical Factors	Exercise Oxygen Consumption:			6-General Medical Factors	Any previous Malignancy//Specify:
7-Heart Medical Factors	Exercise Oxygen Consumption//ST=	Value or status is reported, not both		6-General Medical Factors(13)	Most Recent Serum Creatinine:
8-Heart/Lung Medical Factors	PA (sys) mm/Hg:			6-General Medical Factors(14)	Most Recent Serum Creatinine//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	PA (sys) mm/Hg//ST=	Value or status is reported, not both		6-General Medical Factors(15)	Total Serum Albumin:
8-Heart/Lung Medical Factors	PA (sys) mm/Hg Inotropes/Vasodilators			6-General Medical Factors(16)	Total Serum Albumin//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	PA (dia) mm/Hg:			13-Heart Medical Factors(1)	Sudden Death:
8-Heart/Lung Medical Factors	PA (dia) mm/Hg//ST=	Value or status is reported, not both		7-Heart Medical Factors(4)	Implantable Defibrillator:
8-Heart/Lung Medical Factors	PA (dia) mm/Hg Inotropes/Vasodilators			7-Heart Medical Factors(5)	Exercise Oxygen Consumption:
8-Heart/Lung Medical Factors	PA (mean) mm/Hg:			7-Heart Medical Factors(6)	Exercise Oxygen Consumption//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	PA (mean) mm/Hg//ST=	Value or status is reported, not both		8-Heart/Lung Medical Factors(1)	PA (sys) mm/Hg:
8-Heart/Lung Medical Factors	PA (mean) mm/Hg Inotropes/Vasodilators			8-Heart/Lung Medical Factors(2)	PA (sys) mm/Hg//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	PCW (mean) mm/Hg:			8-Heart/Lung Medical Factors(3)	PA (sys) mm/Hg Inotropes/Vasodilators
8-Heart/Lung Medical Factors	PCW (mean) mm/Hg//ST=	Value or status is reported, not both		8-Heart/Lung Medical Factors(4)	PA (dia) mm/Hg:
8-Heart/Lung Medical Factors	PCW (mean) mm/Hg Inotropes/Vasodilators			8-Heart/Lung Medical Factors(5)	PA (dia) mm/Hg//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	CO L/min:			8-Heart/Lung Medical Factors(6)	PA (dia) mm/Hg Inotropes/Vasodilators
8-Heart/Lung Medical Factors	CO L/min//ST=	Value or status is reported, not both		8-Heart/Lung Medical Factors(7)	PA (mean) mm/Hg:
8-Heart/Lung Medical Factors	CO L/min Inotropes/Vasodilators			8-Heart/Lung Medical Factors(8)	PA (mean) mm/Hg//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	History of Cigarette Use:			8-Heart/Lung Medical Factors(9)	PA (mean) mm/Hg Inotropes/Vasodilators
8-Hearrt/Lung Medical Condition	Duration of Abstinence:			8-Heart/Lung Medical Factors(10)	PCW (mean) mm/Hg:
8-Heart/Lung Medical Condition	Prior Cardiac Surgery (non-transplant):			8-Heart/Lung Medical Factors(11)	PCW (mean) mm/Hg//ST=	Value or status is reported, not both
8-Heart/Lung Medical Condition	If yes, check all that apply:			8-Heart/Lung Medical Factors(12)	PCW (mean) mm/Hg Inotropes/Vasodilators
8-heart/Lung Medical Condition	Prior Cardiac Surgery type//Specify:			8-Heart/Lung Medical Factors(13)	CO L/min:
				8-Heart/Lung Medical Factors(14)	CO L/min//ST=	Value or status is reported, not both
				8-Heart/Lung Medical Factors(15)	CO L/min Inotropes/Vasodilators
				8-Heart/Lung Medical Factors(16)	History of Cigarette Use:
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].				8-Hearrt/Lung Medical Condition	Duration of Abstinence:
				8-Heart/Lung Medical Condition	Prior Thoracic Surgery other than prior transplant:
				8-Heart/Lung Medical Condition	Prior Thoracic Surgery//If yes, number of prior sternotomies:
				8-Heart/Lung Medical Condition	Prior Thoracic Surgery//If yes, number of prior thoracotomies:
				8-Heart/Lung Medical Condition	Prior Thoracic Surgery//Prior congenital cardiac surgery:
				8-Heart/Lung Medical Condition	Prior congenital cardiac surgery//If yes, palliative surgery:
				8-Heart/Lung Medical Condition	Prior congenital cardiac surgery//If yes, corrective surgery:
				8-Heart/Lung Medical Condition	Prior congenital cardiac surgery//If yes, single ventricular physiology:
				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].