19 HeartLung Transplant Recipient Registration_Form.xlsx

TRR - Heart/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	Display Only - Cascades from TCR		1-Recipient Information	Organ	Display Only - Cascades from TCR
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	Not required		1- Recipient Information	Recipient Middle Initial	Not required
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	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 feedback		1- Recipient Information	Tx Date	Display Only - Cascades from feedback
1- Recipient Information	State of Permanent Residence			1- Recipient Information	State of Permanent Residence
1- Recipient Information	Permanent Zip			1- Recipient Information	Permanent Zip
2 - Provider Information	Recipient Center Code	Display Only - Cascades from TCR		2-Provider Information	Recipient Center Code	Display Only - Cascades from TCR
2 - Provider Information	Recipient Center Type	Display Only - Cascades from TCR		2-Provider Information	Recipient Center Type	Display Only - Cascades from TCR
2-Provider Information	Physician Name			2-Provider Information	Physician Name
2-Provider Information	Physician NPI#			2-Provider Information	Physician NPI#
2-Provider Information	Surgeon Name			2-Provider Information	Surgeon Name
2-Provider Information	Surgeon NPI#			2-Provider Information	Surgeon NPI#
3-DonorInformation	UNOS Donor ID #	Display Only - Cascades from TCR		3-DonorInformation	UNOS Donor ID #	Display Only - Cascades from TCR
3-DonorInformation	Donor Type	Display Only - Cascades from feedback		3-DonorInformation	Donor Type	Display Only - Cascades from feedback
3-DonorInformation	OPO	Display Only - Cascades from feedback		3-DonorInformation	OPO	Display Only - Cascades from feedback
4-Patient Status	Primary Diagnosis			4-Patient Status	Primary Diagnosis
4-Patient Status	Primary Diagnosis//Specify			4-Patient Status	Primary Diagnosis//Specify
4-Patient Status	Date: Last Seen, Retransplanted or Death			4-Patient Status	Date: Last Seen, Retransplanted or Death
4-Patient Status	Patient Status			4-Patient Status	Patient Status
4-Patient Status	Primary Cause of Death			4-Patient Status	Primary Cause of Death
4-Patient Status	Cause of Death//Specify			4-Patient Status	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	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	Date of Admission to Tx Center			4-Patient Status	Date of Admission to Tx Center
4-Patient Status	Date of Discharge from Tx Center			4-Patient Status	Date of Discharge from Tx Center
4-Patient Status	Medical Condition at time of transplant			4-Patient Status	Medical Condition at time of transplant
4-Patient Status	Patient on Life Support			4-Patient Status	Patient on Life Support
4-Patient Status	Extra Corporeal Membrane Oxygenation			4-Patient Status	Extra Corporeal Membrane Oxygenation
4-Patient Status	Intra Aortic Balloon Pump			4-Patient Status	Intra Aortic Balloon Pump
4-Patient Status	Other Mechanism			4-Patient Status	Prostaglandins
4-Patient Status	Other Mechanism, Specify			4-Patient Status	Intravenous Inotropes
4-Patient Status	Prostacyclin Infusion			4-Patient Status	Ventilator
4-Patient Status	Prostacyclin Inhalation			4-Patient Status	Inhaled NO
4-Patient Status	Patient on Ventricular Assist Device			4-Patient Status	Other Mechanism
4-Patient Status	Life Support: VAD Brand1			4-Patient Status	Other Mechanism, Specify
4-Patient Status	Life Support: VAD Brand1//Specify			4-Patient Status	Prostacyclin Infusion
4-Patient Status	Life Support: VAD Brand2			4-Patient Status	Prostacyclin Inhalation
4-Patient Status	Life Support: VAD Brand2//Specify			4-Patient Status	Patient on Ventricular Assist Device
4-Patient Status	Functional Status			4-Patient Status	Life Support: VAD Brand1
4-Patient Status	Working for income			4-Patient Status	Life Support: VAD Brand1//Specify
4-Patient Status	Primary Source of Payment			4-Patient Status	Life Support: VAD Brand2
4-Patient Status	Primary Source of Payment, Specify			4-Patient Status	Life Support: VAD Brand2//Specify
5- Pretransplant	Height			4-Patient Status	Functional Status
5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both		4-Patient Status	Academic Progress
5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		4-Patient Status	Academic Activity Level
5- Pretransplant	Weight			4-Patient Status	Primary Source of Payment
5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both		4-Patient Status	Primary Source of Payment, Specify
5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only		4-Patient Status	Cognitive Development
5- Pretransplant	BMI	Display Only - Cascades from Database		4-Patient Status	Motor Development
5- Pretransplant	BMI://%ile	Calculated for display only		5- Pretransplant	Date of Measurement
5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database		5- Pretransplant	Height
5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database		5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both
5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only
5- PreTransplant	HIV Serostatus			5- Pretransplant	Weight
5- PreTransplant	NAT HIV			5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both
5- PreTransplant	CMV Status			5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
6- PreTransplant	HBV Core Antibody			5- Pretransplant	BMI	Display Only - Cascades from Database
5- PreTransplant	HBV Surface Antibody Total			5- Pretransplant	BMI://%ile	Calculated for display only
5- PreTransplant	HBV Surface Antigen			5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database
5- PreTransplant	NAT HBV			5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database
5- PreTransplant	HCV Serostatus			5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
5- PreTransplant	NAT HCV			5- PreTransplant	HIV Serostatus
5- PreTransplant	EBV Serostatus			5- PreTransplant	NAT HIV
5-Pretransplant	PA (sys)mm/Hg			5- PreTransplant	CMV Status
5-Pretransplant	PA (sys)mm/Hg//Status	Value or status is reported, not both		6- PreTransplant	HBV Core Antibody
5-Pretransplant	PA(sys)mm/Hg Inotropes/VASODilators			5- PreTransplant	HBV Surface Antibody Total
5-Pretransplant	PA(dia) mm/Hg			5- PreTransplant	HBV Surface Antigen
5-Pretransplant	PA(dia) mm/HG//Status	Value or status is reported, not both		5- PreTransplant	NAT HBV
5-Pretransplant	PA (dia) mm/Hg Inotropes/Vasodilators			5- PreTransplant	HCV Serostatus
5-Pretransplant	PA(mean) mm/Hg			5- PreTransplant	NAT HCV
5-Pretransplant	PA(mean) mm/Hg//Status	Value or status is reported, not both		5- PreTransplant	EBV Serostatus
5-Pretransplant	PA (mean) mm/Hg Inotropes/Vasodilators			5-Pretransplant	PA (sys)mm/Hg
5-Pretransplant	PCW(mean) mm/Hg			5-Pretransplant	PA (sys)mm/Hg//Status	Value or status is reported, not both
5-Pretransplant	PCW(mean) mm/Hg//Status	Value or status is reported, not both		5-Pretransplant	PA(sys)mm/Hg Inotropes/VASODilators
5-Pretransplant	PCW (mean) mm/Hg Inotropes/Vasodilators			5-Pretransplant	PA(dia) mm/Hg
5-Pretransplant	CO L/min			5-Pretransplant	PA(dia) mm/HG//Status	Value or status is reported, not both
5-Pretransplant	CO L/min//Status	Value or status is reported, not both		5-Pretransplant	PA (dia) mm/Hg Inotropes/Vasodilators
5-Pretransplant	CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators			5-Pretransplant	PA(mean) mm/Hg
5-Pretransplant	Most Recent Serum Creatinine			5-Pretransplant	PA(mean) mm/Hg//Status	Value or status is reported, not both
5-Pretransplant	Most Recent Serum Creatinine//Status	Value or status is reported, not both		5-Pretransplant	PA (mean) mm/Hg Inotropes/Vasodilators
5-Pretransplant	Most Recent Total Bilirubin			5-Pretransplant	PCW(mean) mm/Hg
5-Pretransplant	Most Recent Total Bilirubin//Status	Value or status is reported, not both		5-Pretransplant	PCW(mean) mm/Hg//Status	Value or status is reported, not both
5-Pretransplant	Chronic Steroid Use			5-Pretransplant	PCW (mean) mm/Hg Inotropes/Vasodilators
5-Pretransplant	FVC			5-Pretransplant	CO L/min
5-Pretransplant	FVC % predicted//Status	Value or status is reported, not both		5-Pretransplant	CO L/min//Status	Value or status is reported, not both
5-Pretransplant	FeV1			5-Pretransplant	CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators
5-Pretransplant	FeV1 % predicted//Status	Value or status is reported, not both		5- Pretransplant	Cardiac Index	Display Only - Cascades from Database
5-Pretransplant	pCO2			5-Pretransplant	Most Recent Serum Creatinine
5-Pretransplant	pCO2 mm/Hg//Status	Value or status is reported, not both		5-Pretransplant	Most Recent Serum Creatinine//Status	Value or status is reported, not both
5-Pretransplant	Transfusions			5-Pretransplant	Most Recent Total Bilirubin
5-Pretransplant	Infection Requiring IV Therapy within 2 wks prior to Tx			5-Pretransplant	Most Recent Total Bilirubin//Status	Value or status is reported, not both
5-Pretransplant	Dialysis			5-Pretransplant	Chronic Steroid Use
5-Pretransplant	Prior Cardiac Surgery (non-transplant)			5-Pretransplant	FVC
5-Pretransplant	If yes, check all that apply			5-Pretransplant	FVC % predicted//Status	Value or status is reported, not both
5-Pretransplant	Prior Cardiac Surgery//Specify			5-Pretransplant	FeV1
5-Pretransplant	Prior Lung Surgery (non-transplant)			5-Pretransplant	FeV1 % predicted//Status	Value or status is reported, not both
5-Pretransplant	If yes, check all that apply			5-Pretransplant	pCO2
5-Pretransplant	Prior Lung Surgery//Specify			5-Pretransplant	pCO2 mm/Hg//Status	Value or status is reported, not both
5-Pretransplant	Episode of Ventilatory Support			5-Pretransplant	Transfusions
5-Pretransplant	If yes, indicate most recent timeframe			5-Pretransplant	Infection Requiring IV Therapy within 2 wks prior to Tx
5-Pretransplant	Tracheostomy			5-Pretransplant	Dialysis
6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		5-Pretransplant	Episode of Ventilatory Support
6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback		5-Pretransplant	If yes, indicate most recent timeframe
6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		5-Pretransplant	Tracheostomy
6-Transplant Procedure	Heart Procedure			5-Pretransplant	Prior Thoracic Surgery other than prior transplant
6-Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Heart, Heart-Lung			5-Pretransplant	If yes, number of prior sternotomies
6-Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time)://Status	Value or status is reported, not both		5-Pretransplant	If yes, number of prior thoracotomies
6-Transplant Procedure	Lung(s) perfused prior to transplant?			5-Pretransplant	Prior congenital cardiac surgery
6-Transplant Procedure	Perfusion occurred at:			5-Pretransplant	If yes, palliative surgery
6-Transplant Procedure	Perfusion performed by:			5-Pretransplant	If yes, corrective surgery
6-Transplant Procedure	Total time on perfusion			5-Pretransplant	If yes, single ventricular physiology
6-Transplant Procedure	Lung(s) received at transplant center			5-Pretransplant	Most Recent Anti-A Titer
6-Transplant Procedure	On ice			5-Pretransplant	Most Recent Anti-A Titer//Sample Date
6-Transplant Procedure	On pump			5-Pretransplant	Most Recent Anti-B Titer
6-Transplant Procedure	Right Lung/Enbloc: Stayed on pump Put on ice Left Lung: Stayed on pump Put on ice			5-Pretransplant	Most Recent Anti-B Titer//Sample Date
7-Post Transplant	Graft Status			6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
7-Post Transplant	Date of Graft Failure			6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
7-Post Transplant	Primary Cause of Graft Failure			6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
7-Post Transplant	Primary Cause of Graft Failure// Other Specify			6-Transplant Procedure	Heart Procedure
7 - PostTransplant	Stroke			6-Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Heart, Heart-Lung
7 - PostTransplant	Dialysis			6-Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time)://Status	Value or status is reported, not both
7- Post Transplant	Ventilator Support			6-Transplant Procedure	Lung(s) perfused prior to transplant?
7- Post Transplant	Reintubated			6-Transplant Procedure	Perfusion occurred at:
7 - PostTransplant	Permanent Pacemaker			6-Transplant Procedure	Perfusion performed by:
7 - PostTransplant	Airway Dehiscence			6-Transplant Procedure	Total time on perfusion
7- Post Transplant	Did patient have any acute rejection episodes between transplant and discharge			6-Transplant Procedure	Lung(s) received at transplant center
7- Post Transplant	Intubated at 72 hours			6-Transplant Procedure	On ice
7- Post Transplant	PaO2 at 72 hours			6-Transplant Procedure	On pump
7- Post Transplant	PaO2 at 72 hours//Status	Value or status is reported, not both		6-Transplant Procedure	Right Lung/Enbloc: Stayed on pump Put on ice Left Lung: Stayed on pump Put on ice
7- Post Transplant	FiO2 at 72 hours			7- Post Transplant	Graft Status
7- Post Transplant	FiO2 at 72 hours//Status	Value or status is reported, not both		7- Post Transplant	Date of Graft Failure
7- Post Transplant	ECMO a 72 hours			7- Post Transplant	Primary Cause of Graft Failure
7- Post Transplant	Inhaled NO at 72 hours			7- Post Transplant	Primary Cause of Graft Failure// Other Specify
9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection			7- Post Transplant	Ventilator Support
9- Immunosupression Other	immunosuppression medication			7- Post Transplant	Reintubated
9- Immunosupression Other	immunosuppression medication indication			7 - Post Transplant	Permanent Pacemaker
9- Immunosupression Other	days of induction			7 - Post Transplant	Airway Dehiscence
				7- Post Transplant	Did patient have any acute rejection episodes between transplant and discharge
				7- Post Transplant	Intubated at 72 hours
				7- Post Transplant	PaO2 at 72 hours
PUBLIC BURDEN STATEMENT:				7- Post Transplant	PaO2 at 72 hours//Status	Value or status is reported, not both
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].				7- Post Transplant	FiO2 at 72 hours
				7- Post Transplant	FiO2 at 72 hours//Status	Value or status is reported, not both
				7- Post Transplant	ECMO a 72 hours
				7- Post Transplant	Inhaled NO at 72 hours
				7- Post Transplant	Most Recent Anti-A Titer
				7- Post Transplant	Most Recent Anti-A Titer//Sample Date
				7- Post Transplant	Most Recent Anti-B Titer
				7- Post Transplant	Most Recent Anti-B Titer//Sample Date
				8 - PostTransplant	Stroke
				9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection
				9- Immunosupression Other	immunosuppression medication
				9- Immunosupression Other	immunosuppression medication indication
				9- Immunosupression Other	days of induction
				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].