30 Intestine Transplant Candidate Registration_Form.xlsx

TCR - Intestine - 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		1-Provider Information	Transplant Center Code	Display Only - Cascades from Waitlist
1-Provider Information	Transplant Center Type://Recipient Center	Display Only - Cascades from Waitlist		1-Provider Information	Transplant Center Type://Recipient Center	Display Only - Cascades from Waitlist
2-Candidate Information	Organ Registered:	Display Only - Cascades from Waitlist		2-Candidate Information	Organ Registered:	Display Only - Cascades from Waitlist
2-Candidate Information	Date of Listing or Add:	Display Only - Cascades from Waitlist		2-Candidate Information	Date of Listing or Add:	Display Only - Cascades from Waitlist
2-Candidate Information	Last Name:	Cascades from Waitlist		2-Candidate Information	Last Name:	Cascades from Waitlist
2-Candidate Information	First Name:	Cascades from Waitlist		2-Candidate Information	First Name:	Cascades from Waitlist
2-Candidate Information	Middle Initial://MI:	Not required		2-Candidate Information	Middle Initial://MI:	Not required
2-Candidate Information	Previous Surname:	Not required		2-Candidate Information	Previous Surname:	Not required
2-Candidate Information	SSN:	Display Only - Cascades from Waitlist		2-Candidate Information	SSN:	Display Only - Cascades from Waitlist
2-Candidate Information	Gender:	Cascades from Waitlist		2-Candidate Information	Gender:	Cascades from Waitlist
2-Candidate Information	HIC:	Not required		2-Candidate Information	HIC:	Not required
2-Candidate Information	Date of Birth://DOB:	Cascades from Waitlist		2-Candidate Information	Date of Birth://DOB:	Cascades from Waitlist
2-Candidate Information	State of Permanent Residence:	Cascades from Waitlist		2-Candidate Information	State of Permanent Residence:	Cascades from Waitlist
2-Candidate Information	Permanent ZIP Code:	Cascades from Waitlist		2-Candidate Information	Permanent ZIP Code:	Cascades from Waitlist
2-Candidate Information	Ethnicity/Race:	Cascades from Waitlist		2-Candidate Information	Ethnicity/Race:	Cascades from Waitlist
2-Candidate Information	Citizenship:			2-Candidate Information	Citizenship:
2-Candidate Information	Year of Entry to the U.S.			2-Candidate Information	Year of Entry to the U.S.
2-Candidate Information	Year of Entry to the U.S Status//ST=			2-Candidate Information	Year of Entry to the U.S Status//ST=
2-Candidate Information	Country of Permanent Residence			2-Candidate Information	Country of Permanent Residence
2-Candidate Information	Highest Education Level:			2-Candidate Information	Highest Education Level:
3-Patient Status	Patient on Life Support:			3-Patient Status	Patient on Life Support:
3-Patient Status	Life Support://Ventilator			3-Patient Status	Life Support://Ventilator
3-Patient Status	Life Support://Artificial Liver			3-Patient Status	Life Support://Artificial Liver
3-Patient Status	Life Support://Other Mechanism, Specify			3-Patient Status	Life Support://Other Mechanism, Specify
3-Patient Status	Life Support:Other Mechanism//Specify:			3-Patient Status	Life Support:Other Mechanism//Specify:
3-Patient Status	Functional Status:			3-Patient Status	Functional Status:
3-Patient Status	Working for income:			3-Patient Status	Cognitive Development:
3-Patient Status	Previous Transplant//Organ	Display Only - Cascades from Database		3-Patient Status	Motor Development:
3-Patient Status	Previous Transplant//Date	Display Only - Cascades from Database		3-Patient Status	Academic Progress:
3-Patient Status	Previous Transplant//Graft Fail Date	Display Only - Cascades from Database		3-Patient Status	Academic Activity Level:
3-Patient Status	Previous Pancreas Islet Infusion:			3-Patient Status	Previous Transplant//Organ	Display Only - Cascades from Database
4-Source of Payment	Source of Payment//Primary:			3-Patient Status	Previous Transplant//Date	Display Only - Cascades from Database
4-Source of Payment	Foreign Government//Specify:			3-Patient Status	Previous Transplant//Graft Fail Date	Display Only - Cascades from Database
5-Clinical Information	Height in cm://Height:			4-Source of Payment	Source of Payment//Primary:
5-Clinical Information	Height Status//ST=	Value or status is reported, not both		4-Source of Payment	Foreign Government//Specify:
5-Clinical Information	Height Growth percentiles//%ile	Calculated for display only		5-Clinical Information	Date of Measurement:
5-Clinical Information	Weight in kg://Weight:			5-Clinical Information	Height in cm://Height:
5-Clinical Information	Weight Status//ST=	Value or status is reported, not both		5-Clinical Information	Height Status//ST=	Value or status is reported, not both
5-Clinical Information	Weight Growth percentiles//%ile	Calculated for display only		5-Clinical Information	Height Growth percentiles//%ile	Calculated for display only
5-Clinical Information	BMI:	Display Only - Cascades from Database		5-Clinical Information	Weight in kg://Weight:
5-Clinical Information	BMI://%ile	Calculated for display only		5-Clinical Information	Weight Status//ST=	Value or status is reported, not both
5-Clinical Information	ABO Blood Group:	Display Only - Cascades from Waitlist		5-Clinical Information	Weight Growth percentiles//%ile	Calculated for display only
5-Clinical Information	Primary Diagnosis:			5-Clinical Information	BMI:	Display Only - Cascades from Database
5-Clinical Information	Primary Diagnosis//Specify:			5-Clinical Information	BMI://%ile	Calculated for display only
6-General Medical Factors	Diabetes:			5-Clinical Information	ABO Blood Group:	Display Only - Cascades from Waitlist
6-General Medical Factors	Any previous Malignancy:			5-Clinical Information	Primary Diagnosis:
6-General Medical Factors	Any previous Malignancy//Specify Type:			5-Clinical Information	Primary Diagnosis//Specify:
6-General Medical Factors	Any previous Malignancy//Specify:			5-Clinical Information	Secondary Diagnosis:	Not required
6-General Medical Factors	Total Bilirubin			5-Clinical Information	Secondary Diagnosis//Specify:
				6-General Medical Factors	Diabetes:
				6-General Medical Factors	Any previous Malignancy:
				6-General Medical Factors	Any previous Malignancy//Specify Type:
PUBLIC BURDEN STATEMENT:				6-General Medical Factors	Any previous Malignancy//Specify:
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].				6-General Medical Factors	Total Bilirubin:
				6-General Medical Factors	Total Bilirubin://ST=	Value or status is reported, not both
				7-Liver Medical Factors	Loss of two or more vascular access sites:
				7-Liver Medical Factors	History of Portomesenteric Vein Thrombosis:
				7-Liver Medical Factors	Variceal Bleeding within Last Two Weeks:
				7-Liver Medical Factors	Recurrent sepsis:
				7-Liver Medical Factors	Fungal sepsis:
				7-Liver Medical Factors	Unmanageable fluid-electrolyte losses:
				7-Liver Medical Factors	"Non-Reconstructible" GI tract:
				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].