20 HeartLung Transplant Recipient Follow Up 6 Month_Form.CL

	Fields to be completed by members
	Form Section	Field label	Notes
	1-Recipient Information	Organ Type	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 Last Name	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	HIC	Display Only - Cascades from TCR
	1-Recipient Information	Previous Follow-Up	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	DOB	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	State of Permanent Residence
	1-Recipient Information	Zip Code
	2-Provider Information	Recipient Center Type	Display Only - Cascades from TCR
	2-Provider Information	Recipient Center	Display Only - Cascades from TCR
	2-Provider Information	Followup Center Code	Display Only - Cascades from Database
	2-Provider Information	Followup Center Type	Display Only - Cascades from Database
	3-Donor Information	UNOS Donor ID #	Display Only - Cascades from Database
	3-Donor Information	Donor Type	Display Only - Cascades from Database
	3-Donor Information	OPO	Display Only - Cascades from feedback
	4-Patient Status	Date: Last Seen, Retransplanted or Death
	4-Patient Status	Patient Status
	4-Patient Status	Primary Cause of Death
	4-Patient Status	Primary Cause of Death//Specify
	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	Not required
	4-Patient Status	Contributory Cause of Death//Specify	Not required
	5-Clinical Information	Heart Graft Status
	5-Clinical Information	Heart Date of Graft Failure
	5-Clinical Information	Heart Primary Cause of Graft Failure
	5-Clinical Information	Heart Primary Cause of Graft Failure//Other, Specify
	5-Clinical Information	Graft Status
	5-Clinical Information	Date of Graft Failure
	5-Clinical Information	Primary Cause of Graft Failure
	5-Clinical Information	Primary Cause of Graft Failure// Other Specify
	5-Clinical Information	Date Test Performed	Value or status is reported, not both
	5-Clinical Information	FEV1	Value or status is reported, not both
	5-Clinical Information	FVC	Value or status is reported, not both
	5-Clinical Information	FEF 25-75	Value or status is reported, not both
	5-Clinical Information	Date Test Performed	Value or status is reported, not both
	5-Clinical Information	FEV1	Value or status is reported, not both
	5-Clinical Information	FVC	Value or status is reported, not both
	5-Clinical Information	FEF 25-75	Value or status is reported, not both
	5-Clinical Information	Date Test Performed	Value or status is reported, not both
	5-Clinical Information	FEV1	Value or status is reported, not both
	5-Clinical Information	FVC	Value or status is reported, not both
	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
	5-Clinical Information	HIV Serology
	5-Clinical Information	HIV NAT
	5-Clinical Information	HbsAg
	5-Clinical Information	HBV DNA
	5-Clinical Information	HBV Core Antibody
	5-Clinical Information	HCV Serology
	5-Clinical Information	HCV NAT
	5-Clinical Information	Most Recent Anti-A Titer
	5-Clinical Information	Most Recent Anti-A Titer//Sample Date
	5-Clinical Information	Most Recent Anti-B Titer
	5-Clinical Information	Most Recent Anti-B Titer//Sample Date
	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].