3 Living Donor Follow Up_Form.xlsx

Living Donor Follow-up (LDF)
Fields to be completed by members
Form Section	Field Label	Notes
	Urinalysis
Provider Information	Recipient Center Code
Provider Information	Recipient Center Code
Provider Information	Recipient Center Type	Display Only - Cascades from Database
Provider Information	Recipient Center Name
Provider Information	Follow-up Code	Display Only - Cascades from Database
Provider Information	Follow-up Center Code	Display Only - Cascades from Database
Provider Information	Follow-up Center Type	Display Only - Cascades from Database
Provider Information	Follow-up Center Code
Provider Information	Follow-up Center Provider Number//Follow-up Center
Provider Information	Follow-up Center Name//Follow-up Center
Donor Information	Last Name	Display Only - Cascades from Database
Donor Information	First Name	Display Only - Cascades from Database
Donor Information	DOB	Display Only - Cascades from Database
Donor Information	SSN	Display Only - Cascades from Database
Donor Information	Gender	Display Only - Cascades from Database
Donor Information	Donor ID	Display Only - Cascades from feedback
Donor Information	Recovery Date	Display Only - Cascades from Database
Donor Information	Organ(s) Recovered	Display Only - Cascades from Database
Donor Status	Date of Initial Discharge	Display Only - Cascades from Database
Donor Status	Most Recent Donor Status since//Date of last contact or death
Donor Status	Most Recent Donor Status since
Donor Status	Cause of Death
Donor Status	Cause of Death//Specify
Donor Status	Functional Status
Donor Status	Physical Capacity
Donor Status	Working for Income
Donor Status	Working for Income//If No, Not Working Due To
Donor Status	Working for Income//If Yes
Donor Status	Donor Status//Attempts to Collect
Donor Status	Loss of medical insurance due to donation
Donor Status	Loss of health insurance
Donor Status	Loss of life insurance
Clinical Information	Date
Clinical Information	Current weight
Clinical Information	Weight in lb.
Clinical Information	Weight //Status	Value or status is reported, not both
Clinical Information	Height in Ft
Clinical Information	Height in In
Clinical Information	ER or urgent care visit related to donation since last follow-up
Liver Clinical Information	Date
Liver Clinical Information	Total Bilirubin
Liver Clinical Information	Total Bilirubin //Status	Value or status is reported, not both
Liver Clinical Information	Date
Liver Clinical Information	SGOT/AST
Liver Clinical Information	SGOT/AST //Status	Value or status is reported, not both
Liver Clinical Information	Date
Liver Clinical Information	SGPT/ALT
Liver Clinical Information	SGPT/ALT //Status	Value or status is reported, not both
Liver Clinical Information	Date
Liver Clinical Information	Alkaline Phosphatase
Liver Clinical Information	Alkaline Phosphatase //Status	Value or status is reported, not both
Liver Clinical Information	Date
Liver Clinical Information	Serum Albumin
Liver Clinical Information	Serum Albumin //Status	Value or status is reported, not both
Liver Clinical Information	Date
Liver Clinical Information	Serum Creatinine
Liver Clinical Information	Serum Creatinine //Status	Value or status is reported, not both
Liver Clinical Information	Date
Liver Clinical Information	INR
Liver Clinical Information	INR //Status	Value or status is reported, not both
Liver Clinical Information	Date
Liver Clinical Information	Platelet Count
Liver Clinical Information	Platelet Count//Status	Value or status is reported, not both
Kidney Clinical Information	Date
Kidney Clinical Information	Kidney//Serum Creatinine
Kidney Clinical Information	Kidney Serum Creatinine //Status	Value or status is reported, not both
Kidney Clinical Information	Date
Kidney Clinical Information	Blood Pressure Systolic
Kidney Clinical Information	Blood Pressure Systolic //Status	Value or status is reported, not both
Kidney Clinical Information	Date
Kidney Clinical Information	Blood Pressure Diastolic
Kidney Clinical Information	Blood Pressure Diastolic //Status	Value or status is reported, not both
Kidney Clinical Information	Donor Developed Hypertension Requiring Medication
Kidney Clinical Information	Protein-Creatinine Ratio
Kidney Clinical Information	Urine Protein
Kidney Clinical Information	Maintenance Dialysis
Kidney Clinical Information	Maintenance Dialysis//If Yes, Date First Dialyzed
Kidney Clinical Information	Diabetes
Kidney Clinical Information	Diabetes
Lung Clinical Information	Activity Level
Lung Clinical Information	Chronic Incisional Pain
Complications	Has the donor been readmitted since
Complications	If Yes, Date of First Readmission
Complications	Date of First Readmission //Status	Value or status is reported, not both
Complications	Specify Reason for First Readmission
Complications	Complications since	Display Only - Cascades from Database
Complications	Kidney Complications since	Display Only - Cascades from Database
Complications	Kidney Complications Status//If Yes
Complications	Kidney Complications//Specify
Complications	Liver Complications since	Display Only - Cascades from Database
Complications	Liver Complications Status//If Yes
Complications	Liver Complications//Specify
Complications	Complications//Specify
Recipient Information	Recipient's Last Name	Display Only - Cascades from Database
Recipient Information	Recipient's First Name	Display Only - Cascades from Database
Recipient Information	Recipient's SSN	Display Only - Cascades from Database
Recipient Information	Recipient's Name	Display Only - Cascades from Database
Recipient Information	Transplant Date	Display Only - Cascades from Database
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/202X. 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 0.7 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].