52 VCA Transplant Recipient Follow Up_Form.xlsx

	Fields to be completed by members
	Form Section	Field Label	Notes
	Recipient Information	Recipient First Name	Display Only - Cascades from Removal Worksheet
	Recipient Information	Recipient Last Name	Display Only - Cascades from Removal Worksheet
	Recipient Information	Recipient Middle Initial	Display Only - Cascades from Removal Worksheet
	Recipient Information	DOB	Display Only - Cascades from Removal Worksheet
	Recipient Information	SSN	Display Only - Cascades from Removal Worksheet
	Recipient Information	Gender	Display Only - Cascades from Removal Worksheet
	Recipient Information	HIC	Display Only - Cascades from TRR
	Recipient Information	Transplant Date	Display Only - Cascades from Removal Worksheet
	Recipient Information	State of Permanent Residence
	Recipient Information	Permanent zip code
	Provider Information	Treating Reconstructive Surgeon Name
	Provider Information	Treating Reconstructive Surgeon NPI#
	Provider Information	Treating Transplant Physician Name
	Provider Information	Treating Transplant Physician NPI#
	Provider Information	Follow-up Care Provided By:
	Donor Information	UNOS Donor ID #	Display Only - Cascades from Removal Worksheet
	Donor Information	Donor Type	Display Only - Cascades from Removal Worksheet
	Donor Information	OPO	Display Only - Cascades from Removal Worksheet
	Patient Status	Date Last Seen, Retransplanted, or Death
	Patient Status	Patient Status
	Patient Status	Primary Cause of Death
	Patient Status	Primary Cause of Death - Other Specify
	Patient Status	Has patient been hospitalized since the Last Patient Status Date
	Patient Status	Number of Hospitalizations
	Socio-Demographic Information	Working for income
	Socio-Demographic Information	Working for income - If Yes, indicate the recipient's working status
	Socio-Demographic Information	Working for income - If No, Not Working Due To
	Socio-Demographic Information - Source of Payment	Grant funding
	Socio-Demographic Information - Source of Payment	Institutional funding
	Socio-Demographic Information - Source of Payment	Primary Source of Payment
	Socio-Demographic Information - Source of Payment	Primary Source of Payment - Foreign Government, Specify
	Socio-Demographic Information - Source of Payment	Secondary Source of Payment
	Functional Status	Cognitive Development
	Functional Status	Motor Development
	Functional Status	Psychosocial consult performed
	Functional Status - SF-36 score - Physical Health	Physical Functioning (PF) score
	Functional Status - SF-36 score - Physical Health	Role-Physical (RP) score
	Functional Status - SF-36 score - Physical Health	Bodily Pain (BP) score
	Functional Status - SF-36 score - Physical Health	General Health (GH) score
	Functional Status - SF-36 score - Mental Health	Vitality (VT) score
	Functional Status - SF-36 score - Mental Health	Social Functioning (SF) score
	Functional Status - SF-36 score - Mental Health	Role-Emotional (RE) score
	Functional Status - SF-36 score - Mental Health	Mental Heath (MH) score
	Functional Status - Upper Limb	DASH Score
	Functional Status - Upper Limb	Carroll Test Score - Left
	Functional Status - Upper Limb	Carroll Test Score - Right
	Functional Status - Upper Limb	Sensibility Test - Semmes Weinstein - Left
	Functional Status - Upper Limb	Sensibility Test - Semmes Weinstein - Right
	Functional Status - Craniofacial	Olfactory function restored
	Functional Status - Craniofacial - Sensory Testing	2 point discrimination (mm)
	Functional Status - Craniofacial - Sensory Testing - Hot/cold testing	Can feel heat
	Functional Status - Craniofacial - Sensory Testing - Hot/cold testing	Can feel cold
	Functional Status - Craniofacial - Motor function	Oral competence
	Functional Status - Craniofacial - Motor function	Corneal protection
	Functional Status - Craniofacial	Functional occlusion restored
	Functional Status - Craniofacial	Decannulation (if the patient had a tracheostomy)
	Functional Status - Craniofacial	Feeding Tube Removed (if the patient had a feeding tube to start with)
	Functional Status - Craniofacial - Speech Intelligibility Tests	Speaking rate
	Functional Status - Craniofacial - Speech Intelligibility Tests	Percent Intelligibility
	Clinical Information	Height (inches)
	Clinical Information	Weight (lbs)
	Clinical Information	BMI (Body Mass Index)	Display Only - Calculated
	Clinical Information - Noncompliance	Immunosuppression
	Clinical Information - Noncompliance	Rehabilitation
	Clinical Information - Noncompliance	Level of Activity
	Clinical Information - Noncompliance	Other
	Clinical Information - Noncompliance	Other - Other Specify
	Clinical Information	Graft Status
	Clinical Information	Date of Graft Failure
	Clinical Information - Causes of Graft Failure	Acute Rejection
	Clinical Information - Causes of Graft Failure	Acute Rejection - Banff score
	Clinical Information - Causes of Graft Failure	Acute Rejection - Visual skin changes
	Clinical Information - Causes of Graft Failure	Chronic Rejection
	Clinical Information - Causes of Graft Failure	Chronic Rejection - Visual skin changes
	Clinical Information - Causes of Graft Failure	Ischemia
	Clinical Information - Causes of Graft Failure	Sepsis / Infection
	Clinical Information - Causes of Graft Failure	Trauma
	Clinical Information - Causes of Graft Failure	Patient requested removal
	Clinical Information - Causes of Graft Failure	Non-compliance: immunosuppression
	Clinical Information - Causes of Graft Failure	Non-compliance: rehabilitation
	Clinical Information - Causes of Graft Failure	Non-compliance: level of activity
	Clinical Information - Causes of Graft Failure	Other
	Clinical Information - Causes of Graft Failure	Other - Other Specify
	Clinical Information - Most Recent Lab Data	Serum Creatinine (mg/dL)
	Clinical Information - Most Recent Lab Data	Hemoglobin A1c (%)
	Clinical Information - Most Recent Lab Data	Donor Specific Antibodies (DSA)
	Clinical Information	Did patient have any acute rejection episodes during the follow-up period
	Clinical Information	Did patient have any acute rejection episodes during the follow-up period - Number of episodes
	Clinical Information	{For each episode} Date of acute rejection diagnosis
	Clinical Information	{For each episode} Acute rejection was treated
	Clinical Information	{For each episode} Visual skin changes
	Clinical Information	{For each episode} Biopsy was done to confirm acute rejection
	Clinical Information	{For each episode} Banff Score
	Clinical Information - Complications	New onset diabetes
	Clinical Information - Complications	Metabolic Complications
	Clinical Information - Complications	Infectious Complications
	Clinical Information - Complications	Other Complications
	Clinical Information - Complications	Other Complications - Other Specify
	Clinical Information	Post Transplant Malignancy
	Clinical Information - Post-transplant Malignancy	Donor Related
	Clinical Information - Post-transplant Malignancy - Donor Related	Diagnosis date:
	Clinical Information - Post-transplant Malignancy - Donor Related	Tumor type
	Clinical Information - Post-transplant Malignancy	Recurrence of Pre-Tx Tumor
	Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy	Date of recurrence
	Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy	Type of pre-existing tumor
	Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy	Type of pre-existing tumor - Other, Specify
	Clinical Information - Post-transplant Malignancy	De Novo Solid Tumor
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Diagnosis date
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Skin: //squamous cell:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Skin: //basal cell:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Skin: //melanoma:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Kaposi's sarcoma: cutaneous:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Kaposi's sarcoma: visceral:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Brain:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Brain: //Other specify:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Renal carcinoma - specify site(s):
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Carcinoma of vulva, perineum or penis, scrotum:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Carcinoma of the uterus:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Ovarian:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Testicular:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Esophagus:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Stomach:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Small intestine:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Pancreas:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Larynx:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Tongue, throat:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Thyroid:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Bladder:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Breast:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Prostate:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Colo-rectal:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Primary hepatic tumor:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Metastatic liver tumor:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Lung:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types://Leukemia:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Sarcomas:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Other cancers:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Other Cancers: //Site(s):
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Primary unknown:
	Clinical Information - Post-transplant Malignancy	De Novo Lymphoproliferative disease and Lymphoma
	Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma	PTLD: //Diagnosis date:
	Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma	PTLD: //Pathology:
	Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma	PTLD: Pathology: //Other Specify:
	Treatment	Antiviral
	Treatment	Antibiotic
	Treatment	Antifungal
	Topical Immunosuppressive Medications	Immunosuppression medications
	Topical Immunosuppressive Medications	Immunosuppression medications - Other Specify
	Topical Immunosuppressive Medications	Previous maintenance indication
	Topical Immunosuppressive Medications	Current maintenance indication
	Topical Immunosuppressive Medications	Anti-rejection indication
	Non-Topical Immunosuppressive Medications	Immunosuppression medications
	Non-Topical Immunosuppressive Medications	Immunosuppression medications - Other Specify
	Non-Topical Immunosuppressive Medications	Previous maintenance indication
	Non-Topical Immunosuppressive Medications	Current maintenance indication
	Non-Topical Immunosuppressive Medications	Anti-rejection indication
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	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].