3 Living Donor Follow Up_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Living Donor Follow Up_Form.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
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].

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