41 Pancreas Transplant Recipient Registration_Form.xlsx

TRR - Pancreas - 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	Cognitive Development
4- Patient Status	Primary Source of Payment			4- Patient Status	Motor Development
4- Patient Status	Specify Foreign Government//Specify			4- Patient Status	Academic Progress
5- Pretransplant	Height			4- Patient Status	Academic Activity Level
5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both		4- Patient Status	Primary Source of Payment
5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		4- Patient Status	Specify Foreign Government//Specify
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	Pretransplant Dialysis			5- Pretransplant	BMI://%ile	Calculated for display only
5- PreTransplant	If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis			5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database
5- PreTransplant	If Yes, Date First Dialyzed//Status	Value or status is reported, not both		5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database
5- Pretransplant	Average Daily Insulin Units			5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
5- Pretransplant	Average Daily Insulin Units//Status	Value or status is reported, not both		5- PreTransplant	Pretransplant Dialysis
5- Pretransplant	Serum Creatinine at Time of Tx			5- PreTransplant	If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis
5- Pretransplant	Serum Creatinine at Time of Tx//Status	Value or status is reported, not both		5- PreTransplant	If Yes, Date First Dialyzed//Status	Value or status is reported, not both
5- PreTransplant	HIV Serostatus			5- Pretransplant	Average Daily Insulin Units
5- PreTransplant	NAT HIV			5- Pretransplant	Average Daily Insulin Units//Status	Value or status is reported, not both
5- PreTransplant	CMV Status			5- Pretransplant	Serum Creatinine at Time of Tx
5- PreTransplant	HBV Core Antibody			5- Pretransplant	Serum Creatinine at Time of Tx//Status	Value or status is reported, not both
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	Malignancies between listing and transplant			5- PreTransplant	NAT HBV
5- PreTransplant	If yes, specify type			5- Pretransplant	HCV Serostatus
5- PreTransplant	Malignancies between listing and transplant//Specify			5- PreTransplant	NAT HCV
6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		5- Pretransplant	EBV Serostatus
6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback		5- Pretransplant	Malignancies between listing and transplant
6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		5- Pretransplant	Malignancies between listing and transplant//Specify
6-Transplant Procedure	Graft Placement			5- Pretransplant	If yes, specify type
6-Transplant Procedure	Operative Technique			6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
6-Transplant Procedure	Duct Management			6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
6-Transplant Procedure	Duct Management//Specify			6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
6-Transplant Procedure	Venous Vascular Management			6-Transplant Procedure	Graft Placement
6-Transplant Procedure	Arterial Reconstruction			6-Transplant Procedure	Operative Technique
6-Transplant Procedure	Arterial Reconstruction//Specify			6-Transplant Procedure	Duct Management
6-Transplant Procedure	Venous Extension Graft			6-Transplant Procedure	Duct Management//Specify
6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)			6-Transplant Procedure	Venous Vascular Management
6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)//Status	Value or status is reported, not both		6-Transplant Procedure	Arterial Reconstruction
7- PostTransplant	Pancreas Graft Status			6-Transplant Procedure	Arterial Reconstruction//Specify
7- PostTransplant	Patient using any method of blood sugar control?			6-Transplant Procedure	Venous Extension Graft
7- PostTransplant	Patient on insulin?	New field if pancreas graft status is functioning. Modified label if graft status is failed		6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)
7- PostTransplant	Date insulin resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed		6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)//Status	Value or status is reported, not both
7- PostTransplant	Total insulin dosage units			7- PostTransplant	Pancreas Graft Status
7- PostTransplant	Total insulin dosage units//ST	Value or status is reported, not both		7- PostTransplant	Patient using any method of blood sugar control?
7- PostTransplant	Insulin duration of use			7- PostTransplant	Patient on insulin?	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Insulin duration of use//ST	Value or status is reported, not both		7- PostTransplant	Date insulin resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Patient on oral medication to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed		7- PostTransplant	Total insulin dosage units
7- PostTransplant	Date oral medications resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed		7- PostTransplant	Total insulin dosage units//ST	Value or status is reported, not both
7- PostTransplant	Patient using diet to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed		7- PostTransplant	Insulin duration of use
7- PostTransplant	Date of Graft Failure			7- PostTransplant	Insulin duration of use//ST	Value or status is reported, not both
7- PostTransplant	C-Peptide Value			7- PostTransplant	Patient on oral medication to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	C-Peptide Value://ST=	Value or status is reported, not both		7- PostTransplant	Date oral medications resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Hba1c (%)			7- PostTransplant	Patient using diet to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Hba1c (%)//Status	Value or status is reported, not both		7- PostTransplant	Date of Graft Failure
7- PostTransplant	Pancreas Primary Cause of Graft Failure			7- PostTransplant	C-Peptide Value
7- PostTransplant	Pancreas Primary Cause of Graft Failure//Specify			7- PostTransplant	C-Peptide Value://ST=	Value or status is reported, not both
7- PostTransplant	Pancreas Graft/Vascular Thrombosis			7- PostTransplant	Hba1c (%)
7- PostTransplant	Pancreas Infection			7- PostTransplant	Hba1c (%)//Status	Value or status is reported, not both
7- PostTransplant	Bleeding			7- PostTransplant	Pancreas Primary Cause of Graft Failure
7- PostTransplant	Anastomotic Leak			7- PostTransplant	Pancreas Primary Cause of Graft Failure//Specify
7- PostTransplant	Hyperacute Rejection			7- PostTransplant	Pancreas Graft/Vascular Thrombosis
7- PostTransplant	Pancreas Acute Rejection			7- PostTransplant	Pancreas Infection
7- PostTransplant	Biopsy Proven Isletitis			7- PostTransplant	Bleeding
7- PostTransplant	Pancreatitis			7- PostTransplant	Anastomotic Leak
7- PostTransplant	Other, Specify			7- PostTransplant	Hyperacute Rejection
7- PostTransplant	Pancreatitis			7- PostTransplant	Pancreas Acute Rejection
7- PostTransplant	Anastomotic Leak			7- PostTransplant	Biopsy Proven Isletitis
7- PostTransplant	Abscess or Local Infection			7- PostTransplant	Pancreatitis
7- PostTransplant	Pancreas Transplant Complications: Other	Not required		7- PostTransplant	Other, Specify
7- PostTransplant	Did patient have any acute rejection episodes between transplant and discharge			7- PostTransplant	Pancreatitis
9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection			7- PostTransplant	Anastomotic Leak
9- Immunosupression Other	immunosuppression medication			7- PostTransplant	Abscess or Local Infection
9- Immunosupression Other	immunosuppression medication indication			7- PostTransplant	Pancreas Transplant Complications: Other	Not required
9- Immunosupression Other	days of induction			7- PostTransplant	Did patient have any acute rejection episodes between transplant and discharge
				9- 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].