31 Intestine Transplant Recipient Registration_Form.xlsx

TRR - 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- 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	Surgeon Name			2 - Provider Information	Surgeon Name
2 - Provider Information	NPI#			2 - Provider Information	NPI#
3 - Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback		3 - Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback
3 - Donor Information	Donor Type	Display Only - Cascades from feedback		3 - Donor Information	Donor Type	Display Only - Cascades from feedback
3 - Donor Information	OPO	Display Only - Cascades from feedback		3 - Donor Information	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	Secondary Diagnosis	Not required		4-Patient Status	Secondary Diagnosis	Not required
4-Patient Status	Secondary Diagnosis//Specify	Not required		4-Patient Status	Secondary Diagnosis//Specify	Not required
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	Not required		4-Patient Status	Date of Discharge from Tx Center	Not required
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	Ventilator			4-Patient Status	Ventilator
4-Patient Status	Artificial Liver			4-Patient Status	Artificial Liver
4-Patient Status	Other Mechanism			4-Patient Status	Other Mechanism
4-Patient Status	Other Mechanism, Specify			4-Patient Status	Other Mechanism, Specify
4-Patient Status	Functional Status			4-Patient Status	Functional Status
4-Patient Status	Working for income			4-Patient Status	Academic Progress
4-Patient Status	Primary Source of Payment			4-Patient Status	Academic Activity Level
4-Patient Status	Primary Source of Payment, Specify			4-Patient Status	Primary Source of Payment
5- Pretransplant	Height			4-Patient Status	Primary Source of Payment, Specify
5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both		4-Patient Status	Cognitive Development
5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		4-Patient Status	Motor Development
5- Pretransplant	Weight			5- Pretransplant	Date of Measurement
5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both		5- Pretransplant	Height
5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only		5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both
5- Pretransplant	BMI	Display Only - Cascades from Database		5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only
5- Pretransplant	BMI://%ile	Calculated for display only		5- Pretransplant	Weight
5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database		5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both
5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database		5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		5- Pretransplant	BMI	Display Only - Cascades from Database
5- PreTransplant	HIV Serostatus			5- Pretransplant	BMI://%ile	Calculated for display only
5- PreTransplant	NAT HIV			5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database
5- PreTransplant	CMV Status			5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database
5- PreTransplant	HBV Core Antibody			5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
5- PreTransplant	HBV Surface Antibody Total			5- PreTransplant	HIV Serostatus
5- PreTransplant	HBV Surface Antigen			5- PreTransplant	NAT HIV
5- PreTransplant	NAT HBV			5- PreTransplant	CMV Status
5- PreTransplant	HCV Serostatus			5- PreTransplant	HBV Core Antibody
5- PreTransplant	NAT HCV			5- PreTransplant	HBV Surface Antibody Total
5- PreTransplant	EBV Serostatus			5- PreTransplant	HBV Surface Antigen
5-Pretransplant	Total Bilirubin			5- PreTransplant	NAT HBV
5-Pretransplant	Total Bilirubin//Status	Value or status is reported, not both		5- PreTransplant	HCV Serostatus
5-Pretransplant	Serum Albumin			5- PreTransplant	NAT HCV
5-Pretransplant	Serum Albumin//Status	Value or status is reported, not both		5- PreTransplant	EBV Serostatus
5-Pretransplant	Serum Creatinine			5-Pretransplant	Total Bilirubin
5-Pretransplant	Serum Creatinine//Status	Value or status is reported, not both		5-Pretransplant	Total Bilirubin//Status	Value or status is reported, not both
6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		5-Pretransplant	Serum Albumin
6-Transplant Procedure	Intestine Venous Drainage			5-Pretransplant	Serum Albumin//Status	Value or status is reported, not both
6-Transplant Procedure	Native Viscera Venous Drainage			5-Pretransplant	Serum Creatinine
6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		5-Pretransplant	Serum Creatinine//Status	Value or status is reported, not both
6-Transplant Procedure	Stomach			6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
6-Transplant Procedure	Small Intestine			6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
6-Transplant Procedure	Duodenum			6-Transplant Procedure	Intestine Venous Drainage
6-Transplant Procedure	Large Intestine			6-Transplant Procedure	Native Viscera Venous Drainage
6-Transplant Procedure	Total Ischemic Time (include cold, warm and anastomotic time)			6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
6-Transplant Procedure	Total ischemia Time Hours (include cold, warm and anastomotic time)//Status	Value or status is reported, not both		6-Transplant Procedure	Stomach
6-Transplant Procedure	Recent Septicemia			6-Transplant Procedure	Small Intestine
6-Transplant Procedure	Exhausted Vascular Access			6-Transplant Procedure	Duodenum
6-Transplant Procedure	Previous Abdominal Surgery			6-Transplant Procedure	Large Intestine
6-Transplant Procedure	Dilated/Non-Functional Bowel Segments			6-Transplant Procedure	Total Ischemic Time (include cold, warm and anastomotic time)
6-Transplant Procedure	Other risk factors	Not required		6-Transplant Procedure	Total ischemia Time Hours (include cold, warm and anastomotic time)//Status	Value or status is reported, not both
7- Post Transplant	Graft Status			6-Transplant Procedure	Recent Septicemia
7- Post Transplant	TPN Dependent			6-Transplant Procedure	Exhausted Vascular Access
7- Post Transplant	IV Dependent			6-Transplant Procedure	Previous Abdominal Surgery
7- Post Transplant	Oral Feeding			6-Transplant Procedure	Dilated/Non-Functional Bowel Segments
7- Post Transplant	Tube Feed			6-Transplant Procedure	Other risk factors	Not required
7- Post Transplant	Date of Graft Failure			7- Post Transplant	Graft Status
7- Post Transplant	Primary Cause of Graft Failure			7- Post Transplant	TPN Dependent
7- Post Transplant	Primary Cause of Graft Failure//Specify			7- Post Transplant	IV Dependent
7 - PostTransplant	Did patient have any acute rejection episodes between transplant and discharge			7- Post Transplant	Oral Feeding
10- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection			7- Post Transplant	Tube Feed
9- Immunosupression Other	immunosuppression medication			7- Post Transplant	Date of Graft Failure
9- Immunosupression Other	immunosuppression medication indication			7- Post Transplant	Primary Cause of Graft Failure
9- Immunosupression Other	days of induction			7- Post Transplant	Primary Cause of Graft Failure//Specify
				7 - PostTransplant	Did patient have any acute rejection episodes between transplant and discharge
				10- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection
				9- Immunosupression Other	immunosuppression medication
PUBLIC BURDEN STATEMENT:				9- Immunosupression Other	immunosuppression medication indication
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].				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].