Form 21 HeartLung Transplant Recipient Follow Up 1_5 Year_Form.C

TRF (1-5 Year) - 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 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	Ejection Fraction	Value or status is reported, not both		5-Clinical Information	Weight//Status	Value or status is reported, not both
5-Clinical Information	Heart: Ejection Fraction//Status	Display Only - Cascades from Database		5-Clinical Information	Weight Percentile	Calculated for display only
5-Clinical Information	Pacemaker	Display Only - Cascades from Database		5-Clinical Information	BMI	Display Only - Cascades from Database
5-Clinical Information	Coronary Artery Disease	Display Only - Cascades from Database		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	Date Test Performed	Value or status is reported, not both		5-Clinical Information	Date of Graft Failure
5-Clinical Information	FEV1	Value or status is reported, not both		5-Clinical Information	Primary Cause of Graft Failure
5-Clinical Information	FVC	Value or status is reported, not both		5-Clinical Information	Primary Cause of Graft Failure//Other, Specify
5-Clinical Information	FEF 25-75	Value or status is reported, not both		5-Clinical Information	Most Recent Anti-A Titer
5-Clinical Information	Current Supplemental O2 requirements at rest and/or at exercise			5-Clinical Information	Most Recent Anti-A Titer//Sample Date
5-Clinical Information	At rest: FiO2 or Flow	Value or status is reported, not both		5-Clinical Information	Most Recent Anti-B Titer
5-Clinical Information	With excercise: FiO2 or Flow	Value or status is reported, not both		5-Clinical Information	Most Recent Anti-B Titer//Sample Date
5-Clinical Information	New diabetes onset between last follow-up to the current follow-up			5-Clinical Information	Ejection Fraction	Display Only - Cascades from Database
5-Clinical Information	Diabetes: If Yes, Insulin Dependent			5-Clinical Information	Heart: Ejection Fraction//Status	Value or status is reported, not both
5-Clinical Information	Most Recent Serum Creatinine			5-Clinical Information	Shortening Fraction	Display Only - Cascades from Database
5-Clinical Information	Most Recent Serum Creatinine//Status	Value or status is reported, not both		5-Clinical Information	Shortening Fraction://Status	Value or status is reported, not both
5-Clinical Information	Chronic Dialysis			5-Clinical Information	Pacemaker	Display Only - Cascades from Database
5-Clinical Information	Renal Tx since Thoracic Tx			5-Clinical Information	Coronary Artery Disease Since Last Follow Up	Display Only - Cascades from Database
5-Clinical Information	Did patient have any acute rejection episodes during the follow-up period			5-Clinical Information	Date Test Performed	Value or status is reported, not both
5-Clinical Information	Post Transplant Malignancy			5-Clinical Information	FEV1	Value or status is reported, not both
5-Clinical Information	Donor Related			5-Clinical Information	FVC	Value or status is reported, not both
5-Clinical Information	Recurrence of Pre-Tx Tumor			5-Clinical Information	FEF 25-75	Value or status is reported, not both
5-Clinical Information	De Novo Solid Tumor			5-Clinical Information	Date Test Performed	Value or status is reported, not both
5-Clinical Information	De Novo Lymphoproliferative disease and Lymphoma			5-Clinical Information	FEV1	Value or status is reported, not both
5-Clinical Information	Other, Specify			5-Clinical Information	FVC	Value or status is reported, not both
7-Immunosuppressive Information	Were any medications given during the follow-up period for maintenance			5-Clinical Information	FEF 25-75	Value or status is reported, not both
7-Immunosuppressive Information	Previous Validated Maintenance Follow-Up Medications	Display Only - Cascades from Database		5-Clinical Information	Date Test Performed	Value or status is reported, not both
7-Immunosuppressive Information	immunosuppression medication			5-Clinical Information	FEV1	Value or status is reported, not both
7-Immunosuppressive Information	immunosuppression medication indication			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
PUBLIC BURDEN STATEMENT:				5-Clinical Information	At rest: FiO2 or Flow	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].				5-Clinical Information	With excercise: FiO2 or Flow	Value or status is reported, not both
				5-Clinical Information	New diabetes onset between last follow-up to the current follow-up
				5-Clinical Information	Diabetes: If Yes, Insulin Dependent
				5-Clinical Information	Most Recent Serum Creatinine
				5-Clinical Information	Most Recent Serum Creatinine//Status	Value or status is reported, not both
				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-Immunosuppressive Information	immunosuppression medication
				7-Immunosuppressive Information	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].