15 Lung Transplant Recipient Follow Up 1_5 Year_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Lung Transplant Recipient Follow Up 1_5 Year_Form.xlsx

Lung Transplant Recipient Follow Up 1-5 Year (TRF)

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRF (1-5 Year) - Lung - 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 Type Display Only - Cascades from TCR
1-Recipient Information Previous Follow-Up Display Only - Cascades from prior TRF
2-Provider Information Recipient Center Display Only - Cascades from TCR
1-Recipient Information Previous Px Stat Date Display Only - Cascades from prior TRF
2-Provider Information Followup Center Code Display Only - Cascades from Database
2-Provider Information Recipient Center Type Display Only - Cascades from TCR
2-Provider Information Followup Center Type Display Only - Cascades from Database
2-Provider Information Recipient Center Display Only - Cascades from TCR
2-Provider Information Physician Name
2-Provider Information Followup Center Code Display Only - Cascades from Database
2-Provider Information NPI#
2-Provider Information Followup Center Type Display Only - Cascades from Database
2-Provider Information Follow-up Care Provided By
2-Provider Information Physician Name
2-Provider Information Follow-up Care Provided By//Specify
2-Provider Information NPI#
3- Donor Information UNOS Donor ID # Display Only - Cascades from Database
2-Provider Information Follow-up Care Provided By
3- Donor Information Donor Type Display Only - Cascades from Database
2-Provider Information Follow-up Care Provided By//Specify
3- Donor Information OPO Display Only - Cascades from feedback
3- Donor Information UNOS Donor ID # Display Only - Cascades from Database
4-Patient Status Date: Last Seen, Retransplanted or Death
3- Donor Information Donor Type Display Only - Cascades from Database
4-Patient Status Patient Status
3- Donor Information OPO Display Only - Cascades from feedback
4-Patient Status Primary Cause of Death
4-Patient Status Date: Last Seen, Retransplanted or Death
4-Patient Status Primary Cause of Death//Specify
4-Patient Status Patient Status
4-Patient Status Contributory Cause of Death Not required
4-Patient Status Primary Cause of Death
4-Patient Status Contributory Cause of Death//Specify Not required
4-Patient Status Primary Cause of Death//Specify
4-Patient Status Contributory Cause of Death Not required
4-Patient Status Contributory Cause of Death Not required
4-Patient Status Contributory Cause of Death//Specify Not required
4-Patient Status Contributory Cause of Death//Specify Not required
4-Patient Status Has the patient been hospitalized since the last patient status date
4-Patient Status Contributory Cause of Death Not required
4-Patient Status Hospitalized for Rejection
4-Patient Status Contributory Cause of Death//Specify Not required
4-Patient Status Hospitalized for Infection
4-Patient Status Has the patient been hospitalized since the last patient status date
4-Patient Status Functional Status
4-Patient Status Hospitalized for Rejection
4-Patient Status Working for income
4-Patient Status Hospitalized for Infection
4-Patient Status Primary Insurance at Follow-up
4-Patient Status Functional Status
4-Patient Status Primary Source of Payment, Specify
4-Patient Status at Time of Follow-Up Cognitive Development
5-Clinical Information HIV Serology

4-Patient Status at Time of Follow-Up Motor Development
5-Clinical Information HIV NAT

4-Patient Status Working for income
5-Clinical Information HbsAg

4-Patient Status Academic Progress
5-Clinical Information HBV DNA

4-Patient Status Academic Activity Level
5-Clinical Information HBV Core Antibody

4-Patient Status Primary Insurance at Follow-up
5-Clinical Information HCV Serology

4-Patient Status Primary Source of Payment, Specify
5-Clinical Information HCV NAT

5-Clinical Information Date of Measurement
5-Clinical Information Graft Status

5-Clinical Information Height
5-Clinical Information Date of Graft Failure

5-Clinical Information Height//Status Value or status is reported, not both
5-Clinical Information Primary Cause of Graft Failure

5-Clinical Information Height Percentile Calculated for display only
5-Clinical Information Primary Cause of Graft Failure// Other Specify
5-Clinical Information Weight
5-Clinical Information Date Test Performed Value or status is reported, not both
5-Clinical Information Weight//Status Value or status is reported, not both
5-Clinical Information FEV1 Value or status is reported, not both
5-Clinical Information Weight Percentile Calculated for display only
5-Clinical Information FVC Value or status is reported, not both
5-Clinical Information BMI Display Only - Cascades from Database
5-Clinical Information FEF 25-75 Value or status is reported, not both
5-Clinical Information BMI Calculated for display only
5-Clinical Information Date Test Performed Value or status is reported, not both
5-Clinical Information HIV Serology
5-Clinical Information FEV1 Value or status is reported, not both
5-Clinical Information HIV NAT
5-Clinical Information FVC Value or status is reported, not both
5-Clinical Information HbsAg
5-Clinical Information FEF 25-75 Value or status is reported, not both
5-Clinical Information HBV DNA
5-Clinical Information Date Test Performed Value or status is reported, not both
5-Clinical Information HBV Core Antibody
5-Clinical Information FEV1 Value or status is reported, not both
5-Clinical Information HCV Serology
5-Clinical Information FVC Value or status is reported, not both
5-Clinical Information HCV NAT
5-Clinical Information FEF 25-75 Value or status is reported, not both
5-Clinical Information Graft Status
5-Clinical Information Current Supplemental O2 requirements at rest and/or at exercise

5-Clinical Information Date of Graft Failure
5-Clinical Information At rest: FiO2 or Flow Value or status is reported, not both
5-Clinical Information Primary Cause of Graft Failure
5-Clinical Information With excercise: FiO2 or Flow Value or status is reported, not both
5-Clinical Information Primary Cause of Graft Failure// Other Specify
5-Clinical Information New diabetes onset between last follow-up to the current follow-up
5-Clinical Information Most Recent Anti-A Titer
5-Clinical Information Diabetes: If Yes, Insulin Dependent
5-Clinical Information Most Recent Anti-A Titer//Sample Date
5-Clinical Information Most Recent Serum Creatinine
5-Clinical Information Most Recent Anti-B Titer
5-Clinical Information Most Recent Serum Creatinine//Status
5-Clinical Information Most Recent Anti-B Titer//Sample Date
5-Clinical Information Chronic Dialysis
5-Clinical Information Date Test Performed Value or status is reported, not both
5-Clinical Information Renal Tx since Thoracic Tx
5-Clinical Information FEV1 Value or status is reported, not both
5-Clinical Information Did patient have any acute rejection episodes during the follow-up period
5-Clinical Information FVC Value or status is reported, not both
5-Clinical Information Post Transplant Malignancy
5-Clinical Information FEF 25-75 Value or status is reported, not both
5-Clinical Information Donor Related
5-Clinical Information Date Test Performed Value or status is reported, not both
5-Clinical Information Recurrence of Pre-Tx Tumor
5-Clinical Information FEV1 Value or status is reported, not both
5-Clinical Information De Novo Solid Tumor
5-Clinical Information FVC Value or status is reported, not both
5-Clinical Information De Novo Lymphoproliferative disease and Lymphoma
5-Clinical Information FEF 25-75 Value or status is reported, not both
7-Immunosuppressive Information Were any medications given during the follow-up period for maintenance
5-Clinical Information Date Test Performed Value or status is reported, not both
7-Immunosuppressive Information Previous Validated Maintenance Follow-Up Medications Display Only - Cascades from Database
5-Clinical Information FEV1 Value or status is reported, not both
7- Immunosupression Other immunosuppression medication

5-Clinical Information FVC Value or status is reported, not both
7- Immunosupression Other immunosuppression medication indication

5-Clinical Information FEF 25-75 Value or status is reported, not both




5-Clinical Information Current Supplemental O2 requirements at rest and/or at exercise




5-Clinical Information At rest: FiO2 or Flow Value or status is reported, not both




5-Clinical Information With excercise: FiO2 or Flow Value or status is reported, not both
PUBLIC BURDEN STATEMENT:

5-Clinical Information Diabetes onset during the follow-up period
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].


5-Clinical Information Diabetes: If Yes, Insulin Dependent

5-Clinical Information Most Recent Serum Creatinine

5-Clinical Information Most Recent Serum Creatinine//Status

5-Clinical Information Chronic Dialysis

5-Clinical Information Renal Tx since Thoracic Tx

5-Clinical Information Did patient have any acute rejection episodes during the follow-up period

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

7-Immunosuppressive Information Were any medications given during the follow-up period for maintenance

7-Immunosuppressive Information Previous Validated Maintenance Follow-Up Medications Display Only - Cascades from Database

7- Immunosupression Other immunosuppression medication




7- Immunosupression Other immunosuppression medication indication

























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].





















































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