Form 49 KidneyPancreas Post Transplant Malignancy_Form.xlsx

Data System for Organ Procurement and Transplantation Network

KidneyPancreas Post Transplant Malignancy_Form.xlsx

Kidney/Pancreas Post Transplant Malignancy (PTM) Form

OMB: 0915-0157

Document [xlsx]
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Post Transplant Malignancy Form (PTM) - All Organs

Fields to be completed by members





Form Section Field Label Notes

1-Recipient Information Recipient last name Display Only - Cascades from Database

1-Recipient Information Recipient first name Display Only - Cascades from Database

1-Recipient Information Recipient Middle Initial Not required

1-Recipient Information Date of birth Display Only - Cascades from Database

1-Recipient Information Recipient SSN Display Only - Cascades from Database

1-Recipient Information Recipient organ Display Only - Cascades from Database

1-Recipient Information TRF Display Only - Cascades from Database

1-Recipient Information Follow-up code Display Only - Cascades from Database

1-Recipient Information Transplant date Display Only - Cascades from Database

1-Recipient Information Follow-up Center Code Display Only - Cascades from Database

1-Recipient Information Follow-up Center Type Display Only - Cascades from Database

1-Recipient Information Followup Center Display Only - Cascades from Database

1-Recipient Information Transplant Center Code Display Only - Cascades from Database

1-Recipient Information Transplant Center Type Display Only - Cascades from Database

1-Recipient Information Transplant Center Display Only - Cascades from Database

2-Donor Related Diagnosis date:

2-Donor Related Tumor type:

2-Donor Related Tumor Types: Skin: //squamous cell:

2-Donor Related Tumor Types: Skin: //basal cell:

2-Donor Related Tumor Types: Skin: //melanoma:

2-Donor Related Tumor Types: //Kaposi's sarcoma: cutaneous:

2-Donor Related Tumor Types: //Kaposi's sarcoma: visceral:

2-Donor Related Tumor Types: //Brain:

2-Donor Related Tumor Types: Brain: //Other specify:

2-Donor Related Tumor Types: //Renal carcinoma - specify site(s):

2-Donor Related Tumor Types: //Carcinoma of vulva, perineum or penis, scrotum:

2-Donor Related Tumor Types: //Carcinoma of the uterus:

2-Donor Related Tumor Types: //Ovarian:

2-Donor Related Tumor Types: //Testicular:

2-Donor Related Tumor Types: //Esophagus:

2-Donor Related Tumor Types: //Stomach:

2-Donor Related Tumor Types: //Small intestine:

2-Donor Related Tumor Types: //Pancreas:

2-Donor Related Tumor Types: //Larynx:

2-Donor Related Tumor Types: //Tongue, throat:

2-Donor Related Tumor Types: //Thyroid:

2-Donor Related Tumor Types: //Bladder:

2-Donor Related Tumor Types: //Breast:

2-Donor Related Tumor Types: //Prostate:

2-Donor Related Tumor Types: //Colo-rectal:

2-Donor Related Tumor Types: //Primary hepatic tumor:

2-Donor Related Tumor Types: //Metastatic liver tumor:

2-Donor Related Tumor Types: //Lung:

2-Donor Related Tumor Types://Leukemia:

2-Donor Related Tumor Types: //Sarcomas:

2-Donor Related Tumor Types: //Other cancers:

2-Donor Related Other Cancers: //Site(s):

2-Donor Related Tumor Types: //Primary unknown:

3-Recurrence of Pretransplant Malignancy Type of pre-existing tumor:

3-Recurrence of Pretransplant Malignancy If other cancer, specify:

3-Recurrence of Pretransplant Malignancy Date of recurrence (post tx):

4-Post Transplant De Novo Solid Tumor Tumor Types: Skin: //squamous cell:

4-Post Transplant De Novo Solid Tumor Tumor Types: Skin: //basal cell:

4-Post Transplant De Novo Solid Tumor Tumor Types: Skin: //melanoma:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Kaposi's sarcoma: cutaneous:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Kaposi's sarcoma: visceral:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Brain:

4-Post Transplant De Novo Solid Tumor Tumor Types: Brain: //Other specify:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Renal carcinoma - specify site(s):

4-Post Transplant De Novo Solid Tumor Tumor Types: //Carcinoma of vulva, perineum or penis, scrotum:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Carcinoma of the uterus:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Ovarian:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Testicular:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Esophagus:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Stomach:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Small intestine:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Pancreas:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Larynx:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Tongue, throat:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Thyroid:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Bladder:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Breast:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Prostate:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Colo-rectal:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Primary hepatic tumor:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Metastatic liver tumor:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Lung:

4-Post Transplant De Novo Solid Tumor Tumor Types://Leukemia:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Sarcomas:

4-Post Transplant De Novo Solid Tumor Tumor Types: //Other cancers:

4-Post Transplant De Novo Solid Tumor Other Cancers: //Site(s):

4-Post Transplant De Novo Solid Tumor Tumor Types: //Primary unknown:

4-Post Transplant De Novo Solid Tumor Diagnosis date

5-Post Transplant Lymphoproliferative Disease and Lymphoma PTLD: //Diagnosis date:

5-Post Transplant Lymphoproliferative Disease and Lymphoma PTLD: //Pathology:

5-Post Transplant Lymphoproliferative Disease and Lymphoma PTLD: Pathology: //Other Specify:













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].














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