15 Lung Transplant Recipient Follow Up 1_5 Year_Form_clean.

Data System for Organ Procurement and Transplantation Network

Lung Transplant Recipient Follow Up 1_5 Year_Form_clean.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRF (1-5 Year) - Lung - Adult

TRF (1-5 Year) - Lung - 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 Type Display Only - Cascades from Database
Recipient Information Organ Type Display Only - Cascades from Database
Recipient Information Follow-up code Display Only - Cascades from Database
Recipient Information Follow-up code Display Only - Cascades from Database
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 Display Only - Cascades from TCR
Recipient Information Recipient Middle Initial Display Only - Cascades from TCR
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 Previous Follow-up Display Only - Cascades from prior TRF
Recipient Information Previous Follow-up Display Only - Cascades from prior TRF
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 Database
Recipient Information Tx Date Display Only - Cascades from Database
Recipient Information Previous Px Stat Date Display Only - Cascades from prior TRF
Recipient Information Previous Px Stat Date Display Only - Cascades from prior TRF
Recipient Information Transplant Discharge Date
Recipient Information Transplant Discharge Date
Recipient Information State of Permanent Residence
Recipient Information State of Permanent Residence
Recipient Information Zip Code
Recipient Information Zip Code
Provider Information Recipient Center Type Display Only - Cascades from TCR
Recipient Information Previous Follow-up Display Only - Cascades from prior TRF
Provider Information Recipient Center Display Only - Cascades from TCR
Recipient Information Previous Px Stat Date Display Only - Cascades from prior TRF
Provider Information Follow-up Center Code Display Only - Cascades from Database
Provider Information Recipient Center Type Display Only - Cascades from TCR
Provider Information Follow-up Center Type Display Only - Cascades from Database
Provider Information Recipient Center Display Only - Cascades from TCR
Provider Information Physician Name
Provider Information Follow-up Center Code Display Only - Cascades from Database
Provider Information NPI#
Provider Information Follow-up Center Type Display Only - Cascades from Database
Provider Information Follow-up Care Provided By
Provider Information Physician Name
Provider Information Follow-up Care Provided By//Specify
Provider Information NPI#
Donor Information UNOS Donor ID # Display Only - Cascades from Database
Provider Information Follow-up Care Provided By
Donor Information Donor Type Display Only - Cascades from Database
Provider Information Follow-up Care Provided By//Specify
Donor Information OPO Display Only - Cascades from feedback
Donor Information UNOS Donor ID # Display Only - Cascades from Database
Patient Status Date: Last Seen, Retransplanted or Death
Donor Information Donor Type Display Only - Cascades from Database
Patient Status Patient Status
Donor Information OPO Display Only - Cascades from feedback
Patient Status Primary Cause of Death
Patient Status Date: Last Seen, Retransplanted or Death
Patient Status Primary Cause of Death//Specify
Patient Status Patient Status
Patient Status Contributory Cause of Death Not required
Patient Status Primary Cause of Death
Patient Status Contributory Cause of Death//Specify Not required
Patient Status Primary 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 Has the patient been hospitalized since the last patient status date
Patient Status Contributory Cause of Death Not required
Patient Status Hospitalized for Rejection
Patient Status Contributory Cause of Death//Specify Not required
Patient Status Hospitalized for Infection
Patient Status Has the patient been hospitalized since the last patient status date
Patient Status Functional Status
Patient Status Hospitalized for Rejection
Patient Status Working for income
Patient Status Hospitalized for Infection
Patient Status Primary Insurance at Follow-up
Patient Status Functional Status
Patient Status Primary Source of Payment, Specify
Patient Status at Time of Follow-up Cognitive Development
Clinical Information HIV Serology

Patient Status at Time of Follow-up Motor Development
Clinical Information HIV NAT

Patient Status Working for income
Clinical Information HbsAg

Patient Status Academic Progress
Clinical Information HBV DNA

Patient Status Academic Activity Level
Clinical Information HBV Core Antibody

Patient Status Primary Insurance at Follow-up
Clinical Information HCV Serology

Patient Status Primary Source of Payment, Specify
Clinical Information HCV NAT

Clinical Information Height Measurement Date
Clinical Information Graft Status

Clinical Information Height
Clinical Information Date of Graft Failure

Clinical Information Height//Status Value or status is reported, not both
Clinical Information Primary Cause of Graft Failure

Clinical Information Height Percentile Calculated for display only
Clinical Information Primary Cause of Graft Failure// Other Specify
Clinical Information Weight Measurement Date
Clinical Information Date Test Performed Value or status is reported, not both
Clinical Information Weight
Clinical Information FEV1 Value or status is reported, not both
Clinical Information Weight//Status Value or status is reported, not both
Clinical Information FVC Value or status is reported, not both
Clinical Information Weight Percentile Calculated for display only
Clinical Information FEF 25-75 Value or status is reported, not both
Clinical Information BMI Display Only - Cascades from Database
Clinical Information Date Test Performed Value or status is reported, not both
Clinical Information BMI Calculated for display only
Clinical Information FEV1 Value or status is reported, not both
Clinical Information HIV Serology
Clinical Information FVC Value or status is reported, not both
Clinical Information HIV NAT
Clinical Information FEF 25-75 Value or status is reported, not both
Clinical Information HbsAg
Clinical Information Date Test Performed Value or status is reported, not both
Clinical Information HBV DNA
Clinical Information FEV1 Value or status is reported, not both
Clinical Information HBV Core Antibody
Clinical Information FVC Value or status is reported, not both
Clinical Information HCV Serology
Clinical Information FEF 25-75 Value or status is reported, not both
Clinical Information HCV NAT
Clinical Information Current Supplemental O2 requirements at rest and/or at exercise

Clinical Information Graft Status
Clinical Information At rest: FiO2 or Flow Value or status is reported, not both
Clinical Information Date of Graft Failure
Clinical Information With exercise: FiO2 or Flow Value or status is reported, not both
Clinical Information Primary Cause of Graft Failure
Clinical Information New diabetes onset between last follow-up to the current follow-up
Clinical Information Primary Cause of Graft Failure// Other Specify
Clinical Information Diabetes: If Yes, Insulin Dependent
Clinical Information Most Recent Anti-A Titer
Clinical Information Most Recent Serum Creatinine
Clinical Information Most Recent Anti-A Titer//Sample Date
Clinical Information Most Recent Serum Creatinine//Status
Clinical Information Most Recent Anti-B Titer
Clinical Information Chronic Dialysis
Clinical Information Most Recent Anti-B Titer//Sample Date
Clinical Information Renal Tx since Thoracic Tx
Clinical Information Date Test Performed Value or status is reported, not both
Clinical Information Did patient have any acute rejection episodes during the follow-up period
Clinical Information FEV1 Value or status is reported, not both
Clinical Information Post Transplant Malignancy
Clinical Information FVC Value or status is reported, not both
Clinical Information Donor Related
Clinical Information FEF 25-75 Value or status is reported, not both
Clinical Information Recurrence of Pre-Tx Tumor
Clinical Information Date Test Performed Value or status is reported, not both
Clinical Information De Novo Solid Tumor
Clinical Information FEV1 Value or status is reported, not both
Clinical Information De Novo Lymphoproliferative disease and Lymphoma
Clinical Information FVC Value or status is reported, not both
Immunosuppressive Information Were any medications given during the follow-up period for maintenance
Clinical Information FEF 25-75 Value or status is reported, not both
Immunosuppressive Information Previous Validated Maintenance Follow-up Medications Display Only - Cascades from Database
Clinical Information Date Test Performed Value or status is reported, not both
Immunosuppression Other Immunosuppression medication

Clinical Information FEV1 Value or status is reported, not both
Immunosuppression Other Immunosuppression medication indication

Clinical Information FVC Value or status is reported, not both




Clinical Information FEF 25-75 Value or status is reported, not both



Clinical Information Current Supplemental O2 requirements at rest and/or at exercise




Clinical Information At rest: FiO2 or Flow Value or status is reported, not both
PUBLIC BURDEN STATEMENT:

Clinical Information With exercise: FiO2 or Flow Value or status is reported, not both
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].


Clinical Information Diabetes onset during the follow-up period

Clinical Information Diabetes: If Yes, Insulin Dependent

Clinical Information Most Recent Serum Creatinine

Clinical Information Most Recent Serum Creatinine//Status

Clinical Information Chronic Dialysis

Clinical Information Renal Tx since Thoracic Tx

Clinical Information Did patient have any acute rejection episodes during the follow-up period

Clinical Information Post Transplant Malignancy

Clinical Information Donor Related

Clinical Information Recurrence of Pre-Tx Tumor

Clinical Information De Novo Solid Tumor

Clinical Information De Novo Lymphoproliferative disease and Lymphoma

Immunosuppressive Information Were any medications given during the follow-up period for maintenance

Immunosuppressive Information Previous Validated Maintenance Follow-up Medications Display Only - Cascades from Database




Immunosuppression Other Immunosuppression medication




Immunosuppression Other Immunosuppression medication indication
























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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