36 Kidney Transplant Recipient Registration_Form.xlsx

TRR - Kidney - 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	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	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	Specify Foreign Government//Specify			4 - Patient Status	Primary Source of Payment
5- PreTransplant	Height			4 - Patient Status	Specify Foreign Government//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
6- PreTransplant	Previous Transplant Organ	Display Only - Cascades from Database		5- PreTransplant	Weight in Kilograms//Status	Value or status is reported, not both
6- PreTransplant	Previous Transplant Date	Display Only - Cascades from Database		5- PreTransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
6- PreTransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		5- PreTransplant	BMI	Display Only - Cascades from Database
6- PreTransplant	Pretransplant Dialysis			5- PreTransplant	BMI://%ile	Calculated for display only
6- PreTransplant	If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis			6- PreTransplant	Previous Transplant Organ	Display Only - Cascades from Database
6- PreTransplant	Date First Dialyzed//Status	Value or status is reported, not both		6- PreTransplant	Previous Transplant Date	Display Only - Cascades from Database
6- PreTransplant	Serum Creatinine at Time of Tx			6- PreTransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
6- PreTransplant	Serum Creatinine at Time of Tx//Status	Value or status is reported, not both		6- PreTransplant	Pretransplant Dialysis
6- PreTransplant	HIV Serostatus			6- PreTransplant	If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis
5- PreTransplant	NAT HIV			6- PreTransplant	Date First Dialyzed//Status	Value or status is reported, not both
5- PreTransplant	CMV Status			6- PreTransplant	Serum Creatinine at Time of Tx
6- PreTransplant	HBV Core Antibody			6- PreTransplant	Serum Creatinine at Time of Tx//Status	Value or status is reported, not both
5- PreTransplant	HBV Surface Antibody Total			6- PreTransplant	HIV Serostatus
6- PreTransplant	HBV Surface Antigen			5- PreTransplant	NAT HIV
5- PreTransplant	NAT HBV			6- PreTransplant	CMV Status
6- PreTransplant	HCV Serostatus			6- PreTransplant	HBV Core Antibody
5- PreTransplant	NAT HCV			6- PreTransplant	HBV Surface Antibody Total
6- PreTransplant	EBV Serostatus			6- PreTransplant	HBV Core Antibody
6- PreTransplant	Previous Pregnancies			6- PreTransplant	HBV Surface Antigen
6- PreTransplant	Malignancies between listing and transplant			5- PreTransplant	NAT HBV
6- PreTransplant	If yes, specify type			6- PreTransplant	HCV Serostatus
6- PreTransplant	Malignancies between listing and transplant//Specify			5- PreTransplant	NAT HCV
7 - Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		6- PreTransplant	EBV Serostatus
7 - Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback		6- PreTransplant	Malignancies between listing and transplant
7 - Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		6- PreTransplant	If yes, specify type
7 - Transplant Procedure	Total Cold ischemia Time Right KI(OR EN-BLOC): (if pumped, include pump time)			6- PreTransplant	Malignancies between listing and transplant//Specify
7-Transplant Procedure	Total Cold Ischemia Time//Status	Value or status is reported, not both		6- PreTransplant	Fracture in the past year (or since last follow-up)
7-Transplant Procedure	Total Cold ischemia Time Left KI (if pumped, include pump time)			6- PreTransplant	Spine-compression fracture
7-Transplant Procedure	Total Cold Ischemia Time//Status	Value or status is reported, not both		6- PreTransplant	Spine-compression fracture//# of fractures
7-Transplant Procedure	Kidney(s) received on			6- PreTransplant	Extremity
7-Transplant Procedure	Received on ice			6- PreTransplant	Extremity//# of fractures
7-Transplant Procedure	Received on pump			6- PreTransplant	Other
7-Transplant Procedure	Left Kidney Final resistance at transplant			6- PreTransplant	Other//# of fractures
7-Transplant Procedure	Left Kidney Final resistance at tx//Status	Value or status is reported, not both		6- PreTransplant	AVN (avascular necrosis)
7-Transplant Procedure	Right Kidney Final resistance at transplant			7 - Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
7-Transplant Procedure	Right Kidney Final resistance at tx//Status	Value or status is reported, not both		7 - Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
7-Transplant Procedure	Left Kidney Final flow rate at transplant			7 - Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
7-Transplant Procedure	Left Kidney Final flow rate at tx//Status	Value or status is reported, not both		7 - Transplant Procedure	Total Cold ischemia Time Right KI(OR EN-BLOC): (if pumped, include pump time)
7-Transplant Procedure	Right Kidney Final flow rate at transplant			7-Transplant Procedure	Total Cold Ischemia Time//Status	Value or status is reported, not both
7-Transplant Procedure	Right Kidney Final flow rate at tx//Status	Value or status is reported, not both		7-Transplant Procedure	Total Cold ischemia Time Left KI (if pumped, include pump time)
8- Post Transplant	Graft Status			7-Transplant Procedure	Total Cold Ischemia Time//Status	Value or status is reported, not both
8- Post Transplant	Date of Graft Failure:			7-Transplant Procedure	Kidney(s) received on
8- Post Transplant	Primary Cause of Graft Failure:			7-Transplant Procedure	Received on ice
8- Post Transplant	Primary Cause of Graft Failure//Other, Specify:			7-Transplant Procedure	Received on pump
8 - PostTransplant	Resumed Maintenance Dialysis			7-Transplant Procedure	Left Kidney Final resistance at transplant
8 - PostTransplant	Date Maintenance Dialysis Resumed			7-Transplant Procedure	Left Kidney Final resistance at tx//Status	Value or status is reported, not both
8 -Post Reansplant	Most Recent Serum Creatinine Prior to Discharge			7-Transplant Procedure	Right Kidney Final resistance at transplant
8 -Post Reansplant	Most Recent Serum Creatinine Prior to Disch.//Status	Value or status is reported, not both		7-Transplant Procedure	Right Kidney Final resistance at tx//Status	Value or status is reported, not both
8 - PostTransplant	Patient Need Dialysis within First Week			7-Transplant Procedure	Left Kidney Final flow rate at transplant
8 - PostTransplant	Did patient have any acute rejection episodes between transplant and discharge			7-Transplant Procedure	Left Kidney Final flow rate at tx//Status	Value or status is reported, not both
9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection			7-Transplant Procedure	Right Kidney Final flow rate at transplant
9- Immunosupression Other	immunosuppression medication			7-Transplant Procedure	Right Kidney Final flow rate at tx//Status	Value or status is reported, not both
9- Immunosupression Other	immunosuppression medication indication			8- Post Transplant	Graft Status
9- Immunosupression Other	days of induction			8- Post Transplant	Date of Graft Failure:
				8- Post Transplant	Primary Cause of Graft Failure:
				8- Post Transplant	Primary Cause of Graft Failure//Other, Specify:
				8 - PostTransplant	Resumed Maintenance Dialysis
PUBLIC BURDEN STATEMENT:				8 - PostTransplant	Date Maintenance Dialysis Resumed
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].				8 -Post Reansplant	Most Recent Serum Creatinine Prior to Discharge
				8 -Post Reansplant	Most Recent Serum Creatinine Prior to Disch.//Status	Value or status is reported, not both
				8 - PostTransplant	Patient Need Dialysis within First Week
				8 - PostTransplant	Did patient have any acute rejection episodes between transplant and discharge
				6- PreTransplant	Is growth hormone therapy used between listing and transplant
				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].