Heart Recepient Registration

Data System for Organ Procurement and Transplantation Network

Heart Transplant Recipient Registration_Form_redline.xlsx

Heart Recepient Registration

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRR - Heart - Adult

TRR - Heart - Pediatric
Fields to be completed by members

Fields to be completed by members





Form Section Field Label Notes
Form Section Field Label Notes
Recipient Information Organ Display Only - Cascades from TCR
Recipient Information Organ Display Only - Cascades from TCR
Recipient Information Recipient First Name Display Only - Cascades from TCR
Recipient Information Recipient First Name Display Only - Cascades from TCR
Recipient Information Recipient Last Name Display Only - Cascades from TCR
Recipient Information Recipient Last Name Display Only - Cascades from TCR
Recipient Information Recipient Middle Initial Not required
Recipient Information Recipient Middle Initial Not required
Recipient Information SSN Display Only - Cascades from TCR
Recipient Information SSN Display Only - Cascades from TCR
Recipient Information HIC Display Only - Cascades from TCR
Recipient Information HIC Display Only - Cascades from TCR
Recipient Information DOB Display Only - Cascades from TCR
Recipient Information DOB Display Only - Cascades from TCR
Recipient Information Gender Display Only - Cascades from TCR
Recipient Information Gender Display Only - Cascades from TCR
Recipient Information Tx Date Display Only - Cascades from feedback
Recipient Information Tx Date Display Only - Cascades from feedback
Recipient Information State of Permanent Residence
Recipient Information State of Permanent Residence
Recipient Information Permanent Zip
Recipient Information Permanent Zip
Provider Information Recipient Center Code Display Only - Cascades from TCR
Provider Information Recipient Center Code Display Only - Cascades from TCR
Provider Information Recipient Center Type Display Only - Cascades from TCR
Provider Information Recipient Center Type Display Only - Cascades from TCR
Provider Information Physician Name
Provider Information Physician Name
Provider Information Physician NPI#
Provider Information Physician NPI#
Provider Information Surgeon Name
Provider Information Surgeon Name
Provider Information Surgeon NPI#
Provider Information Surgeon NPI#
Donor Information UNOS Donor ID # Display Only - Cascades from TCR
Donor Information UNOS Donor ID # Display Only - Cascades from TCR
Donor Information Donor Type Display Only - Cascades from feedback
Donor Information Donor Type Display Only - Cascades from feedback
Donor Information OPO Display Only - Cascades from feedback
Donor Information OPO Display Only - Cascades from feedback
Patient Status Primary Diagnosis
Patient Status Primary Diagnosis
Patient Status Primary Diagnosis//Specify
Patient Status Primary Diagnosis//Specify
Patient Status Date: Last Seen, Retransplanted or Death
Patient Status Date: Last Seen, Retransplanted or Death
Patient Status Patient Status
Patient Status Patient Status
Patient Status Primary Cause of Death
Patient Status Primary Cause of Death
Patient Status Cause of Death//Specify
Patient Status Cause of Death//Specify
Patient Status Contributory Cause of Death Not required
Patient Status Contributory Cause of Death Not required
Patient Status Contributory Cause of Death//Specify Not required
Patient Status Contributory Cause of Death//Specify Not required
Patient Status Contributory Cause of Death Not required
Patient Status Contributory Cause of Death Not required
Patient Status Contributory Cause of Death//Specify Not required
Patient Status Contributory Cause of Death//Specify Not required
Patient Status Date of Admission to Tx Center
Patient Status Date of Admission to Tx Center
Patient Status Date of Discharge from Tx Center
Patient Status Date of Discharge from Tx Center
Patient Status Medical Condition at time of transplant
Patient Status Medical Condition at time of transplant
Patient Status Patient on Life Support
Patient Status Patient on Life Support
Patient Status Extra Corporeal Membrane Oxygenation
Patient Status Extra Corporeal Membrane Oxygenation
Patient Status Intra Aortic Balloon Pump
Patient Status Intra Aortic Balloon Pump
Patient Status Prostaglandins
Patient Status Prostaglandins
Patient Status Intravenous Inotropes
Patient Status Intravenous Inotropes
Patient Status Inhaled NO
Patient Status Ventilator
Patient Status Ventilator
Patient Status Inhaled NO
Patient Status Other Mechanism
Patient Status Other Mechanism
Patient Status Other Mechanism, Specify
Patient Status Other Mechanism, Specify
Patient Status Patient on Ventricular Assist Device
Patient Status Patient on Ventricular Assist Device
Patient Status Life Support: VAD Brand1
Patient Status Life Support: VAD Brand1
Patient Status Life Support: VAD Brand1//Specify
Patient Status Life Support: VAD Brand1//Specify
Patient Status Life Support: VAD Brand2
Patient Status Life Support: VAD Brand2
Patient Status Life Support: VAD Brand2//Specify
Patient Status Life Support: VAD Brand2//Specify
Patient Status Functional Status
Patient Status Functional Status
Patient Status Working for income
Patient Status Academic Progress
Pretransplant Height
Patient Status Academic Activity Level
Pretransplant Height in Centimeters//Status Value or status is reported, not both
Patient Status Primary Source of Payment
Pretransplant Height Percentile//Growth Percentiles//%ile Calculated for display only
Patient Status Primary Source of Payment, Specify
Pretransplant Weight
Patient Status Cognitive Development
Pretransplant Weight in Kilograms//Status Value or status is reported, not both
Patient Status Motor Development
Pretransplant Weight Percentile//Growth Percentiles//%ile Calculated for display only
Pretransplant Date of Measurement
Pretransplant BMI Display Only - Cascades from Database
Pretransplant Height
Pretransplant BMI://%ile Calculated for display only
Pretransplant Height in Centimeters//Status Value or status is reported, not both
Pretransplant Previous Transplant Organ Display Only - Cascades from Database
Pretransplant Height Percentile//Growth Percentiles//%ile Calculated for display only
Pretransplant Previous Transplant Date Display Only - Cascades from Database
Pretransplant Weight
Pretransplant Previous Transplant Graft Fail Date Display Only - Cascades from Database
Pretransplant Weight in Kilograms//Status Value or status is reported, not both
Pretransplant HIV Serostatus
Pretransplant Weight Percentile//Growth Percentiles//%ile Calculated for display only
Pretransplant NAT HIV

Pretransplant BMI Display Only - Cascades from Database
Pretransplant CMV Status

Pretransplant BMI://%ile Calculated for display only
Pretransplant HBV Core Antibody
Pretransplant Previous Transplant Organ Display Only - Cascades from Database
Pretransplant HBV Surface Antibody Total

Pretransplant Previous Transplant Date Display Only - Cascades from Database
Pretransplant HBV Surface Antigen
Pretransplant Previous Transplant Graft Fail Date Display Only - Cascades from Database
Pretransplant NAT HBV

Pretransplant HIV Serostatus
Pretransplant HCV Serostatus
Pretransplant NAT HIV

Pretransplant NAT HCV

Pretransplant CMV Status

Pretransplant EBV Serostatus
Pretransplant HBV Core Antibody
Pretransplant Did the recipient receive Hepatitis B vaccines prior to transplant?

Pretransplant HBV Surface Antibody Total

Pretransplant PA (sys)mm/Hg
Pretransplant HBV Surface Antigen
Pretransplant PA (sys)mm/Hg//Status Value or status is reported, not both
Pretransplant NAT HBV

Pretransplant PA(sys)mm/Hg Inotropes/VASODilators
Pretransplant HCV Serostatus
Pretransplant PA(dia) mm/Hg
Pretransplant NAT HCV

Pretransplant PA(dia) mm/HG//Status Value or status is reported, not both
Pretransplant EBV Serostatus
Pretransplant PA (dia) mm/Hg Inotropes/Vasodilators
Pretransplant Did the recipient receive Hepatitis B vaccines prior to transplant?
Pretransplant PA(mean) mm/Hg
Pretransplant PA (sys)mm/Hg
Pretransplant PA(mean) mm/Hg//Status Value or status is reported, not both
Pretransplant PA (sys)mm/Hg//Status Value or status is reported, not both
Pretransplant PA (mean) mm/Hg Inotropes/Vasodilators
Pretransplant PA(sys)mm/Hg Inotropes/VASODilators
Pretransplant PCW(mean) mm/Hg
Pretransplant PA(dia) mm/Hg
Pretransplant PCW(mean) mm/Hg//Status Value or status is reported, not both
Pretransplant PA(dia) mm/HG//Status Value or status is reported, not both
Pretransplant PCW (mean) mm/Hg Inotropes/Vasodilators
Pretransplant PA (dia) mm/Hg Inotropes/Vasodilators
Pretransplant CO L/min
Pretransplant PA(mean) mm/Hg
Pretransplant CO L/min//Status Value or status is reported, not both
Pretransplant PA(mean) mm/Hg//Status Value or status is reported, not both
Pretransplant CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators
Pretransplant PA (mean) mm/Hg Inotropes/Vasodilators
Pretransplant Most Recent Serum Creatinine
Pretransplant PCW(mean) mm/Hg
Pretransplant Most Recent Serum Creatinine//Status Value or status is reported, not both
Pretransplant PCW(mean) mm/Hg//Status Value or status is reported, not both
Pretransplant Most Recent Total Bilirubin
Pretransplant PCW (mean) mm/Hg Inotropes/Vasodilators
Pretransplant Most Recent Total Bilirubin//Status Value or status is reported, not both
Pretransplant CO L/min
Pretransplant Chronic Steroid Use
Pretransplant CO L/min//Status Value or status is reported, not both
Pretransplant Transfusions
Pretransplant CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators
Pretransplant Infection Requiring IV Therapy within 2 wks prior to Tx
Pretransplant Cardiac Index Display Only - Cascades from Database
Pretransplant Dialysis
Pretransplant Most Recent Serum Creatinine
Pretransplant Prior Cardiac Surgery (non-transplant)
Pretransplant Most Recent Serum Creatinine//Status Value or status is reported, not both
Pretransplant If yes, check all that apply
Pretransplant Most Recent Total Bilirubin
Pretransplant Prior Cardiac Surgery//Specify
Pretransplant Most Recent Total Bilirubin//Status Value or status is reported, not both
Pretransplant Prior Lung Surgery (non-transplant)
Pretransplant Chronic Steroid Use
Pretransplant If yes, check all that apply
Pretransplant Transfusions
Pretransplant Prior Lung Surgery//Specify
Pretransplant Infection Requiring IV Therapy within 2 wks prior to Tx
Pretransplant Episode of Ventilatory Support
Pretransplant Dialysis
Pretransplant If yes, indicate most recent timeframe
Pretransplant Episode of Ventilatory Support
Pretransplant Cardiac Index Display Only - Cascades from Database
Pretransplant If yes, indicate most recent timeframe
Transplant Procedure Multiple Organ Recipient Display Only - Cascades from feedback
Pretransplant Prior Thoracic Surgery other than prior transplant
Transplant Procedure Were extra vessels used in the transplant procedure Display Only - Cascades from feedback
Pretransplant If yes, number of prior sternotomies
Transplant Procedure Procedure Type Display Only - Cascades from feedback
Pretransplant If yes, number of prior thoracotomies
Transplant Procedure Heart Procedure
Pretransplant Prior congenital cardiac surgery
Transplant Procedure Total ischemia Time: Heart, Heart-Lung
Pretransplant If yes, palliative surgery
Transplant Procedure Total ischemia Time: Heart, Heart-Lung//Status Value or status is reported, not both
Pretransplant If yes, corrective surgery
Post Transplant Heart Graft Status
Pretransplant If yes, single ventricular physiology
Post Transplant Heart Date of Graft Failure
Pretransplant If yes, specify type
Post Transplant Heart Primary Cause of Graft Failure
Pretransplant Most Recent Anti-A Titer
Post Transplant Heart Primary Cause of Graft Failure//Other Specify

Pretransplant Most Recent Anti-A Titer//Sample Date
Post Transplant Stroke
Pretransplant Most Recent Anti-B Titer
Post Transplant Dialysis
Pretransplant Most Recent Anti-B Titer//Sample Date
Post Transplant Permanent Pacemaker
Transplant Procedure Multiple Organ Recipient Display Only - Cascades from feedback
Post Transplant Airway Dehiscence
Transplant Procedure Were extra vessels used in the transplant procedure Display Only - Cascades from feedback
Post Transplant Did patient have any acute rejection episodes between transplant and discharge
Transplant Procedure Procedure Type Display Only - Cascades from feedback
Post Transplant Primary Cause of Graft Failure//Specify
Transplant Procedure Heart Procedure
Immunosuppression Other Are any medications given currently for maintenance or anti-rejection
Transplant Procedure Total ischemia Time: Heart, Heart-Lung
Immunosuppression Other Immunosuppression medication

Transplant Procedure Total ischemia Time: Heart, Heart-Lung//Status Value or status is reported, not both
Immunosuppression Other Immunosuppression medication indication

Post Transplant Heart Graft Status
Immunosuppression Other Days of induction

Post Transplant Heart Date of Graft Failure




Post Transplant Heart Primary Cause of Graft Failure



Post Transplant Heart Primary Cause of Graft Failure//Other Specify




Post Transplant Stroke
PUBLIC BURDEN STATEMENT:

Post Transplant Reintubated
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].


Post Transplant Permanent Pacemaker

Post Transplant Airway Dehiscence

Post Transplant Did patient have any acute rejection episodes between transplant and discharge

Post Transplant Most Recent Anti-A Titer

Post Transplant Most Recent Anti-A Titer//Sample Date

Post Transplant Most Recent Anti-B Titer

Post Transplant Most Recent Anti-B Titer//Sample Date

Immunosuppression Other Are any medications given currently for maintenance or anti-rejection

Immunosuppression Other Immunosuppression medication


Immunosuppression Other Immunosuppression medication indication


Immunosuppression Other Days of induction



















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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