Form 49 KidneyPancreas Post Transplant Malignancy_Form.xlsx

	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].