18 Heart/Lung Transplant Candidate Registration_Form_clean.

Data System for Organ Procurement and Transplantation Network

HeartLung Transplant Candidate Registration_Form_clean.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TCR - Heart/Lung - Adult
TCR - Heart/Lung - Pediatric
Fields to be completed by members Fields to be completed by members







Form Section Field Label Notes
Form Section Field Label Notes
Provider Information Transplant Center Code Display Only - Cascades from Waitlist
Provider Information Transplant Center Code Display Only - Cascades from Waitlist
Provider Information Transplant Center Type://Recipient Center Display Only - Cascades from Waitlist
Provider Information Transplant Center Type://Recipient Center Display Only - Cascades from Waitlist
Candidate Information Organ Registered: Display Only - Cascades from Waitlist
Candidate Information Organ Registered: Display Only - Cascades from Waitlist
Candidate Information Date of Listing or Add: Display Only - Cascades from Waitlist
Candidate Information Date of Listing or Add: Display Only - Cascades from Waitlist
Candidate Information Last Name: Cascades from Waitlist
Candidate Information Last Name: Cascades from Waitlist
Candidate Information First Name: Cascades from Waitlist
Candidate Information First Name: Cascades from Waitlist
Candidate Information Middle Initial://MI: Not required
Candidate Information Middle Initial://MI: Not required
Candidate Information Previous Surname: Not required
Candidate Information Previous Surname: Not required
Candidate Information SSN: Display Only - Cascades from Waitlist
Candidate Information SSN: Display Only - Cascades from Waitlist
Candidate Information Gender: Cascades from Waitlist
Candidate Information Gender: Cascades from Waitlist
Candidate Information HIC: Not required
Candidate Information HIC: Not required
Candidate Information Date of Birth://DOB: Cascades from Waitlist
Candidate Information Date of Birth://DOB: Cascades from Waitlist
Candidate Information State of Permanent Residence: Cascades from Waitlist
Candidate Information State of Permanent Residence: Cascades from Waitlist
Candidate Information Permanent ZIP Code: Cascades from Waitlist
Candidate Information Permanent ZIP Code: Cascades from Waitlist
Candidate Information Ethnicity/Race: Cascades from Waitlist
Candidate Information Ethnicity/Race: Cascades from Waitlist
Candidate Information Citizenship:

Candidate Information Citizenship:
Candidate Information Year of Entry to the U.S.

Candidate Information Year of Entry to the U.S.
Candidate Information Year of Entry to the U.S Status//ST= Value or status is reported, not both
Candidate Information Year of Entry to the U.S Status//ST=
Candidate Information Country of Permanent Residence

Candidate Information Country of Permanent Residence
Candidate Information Highest Education Level:

Candidate Information Highest Education Level:
Patient Status Patient on Life Support:

Patient Status Patient on Life Support:
Patient Status Life Support://Extra Corporeal Membrane Oxygenation

Patient Status Life Support://Extra Corporeal Membrane Oxygenation
Patient Status Life Support://Intra Aortic Balloon Pump

Patient Status Life Support://Intra Aortic Balloon Pump
Patient Status Life Support://Ventilator

Patient Status Life Support://Ventilator
Patient Status Life Support://Prostacyclin Infusion

Patient Status Life Support://Prostacyclin Infusion
Patient Status Life Support://Prostacyclin Inhalation

Patient Status Life Support://Prostacyclin Inhalation
Patient Status Life Support://Inhaled NO

Patient Status Life Support://Intravenous Inotropes
Patient Status Life Support://Other Mechanism, Specify

Patient Status Life Support://Inhaled NO
Patient Status Life Support:Other Mechanism//Specify:

Patient Status Life Support://Other Mechanism, Specify
Patient Status Life Support://Patient on Ventricular Assist Device:

Patient Status Life Support:Other Mechanism//Specify:
Patient Status Life Support://VAD Brand1:

Patient Status Life Support://Patient on Ventricular Assist Device:
Patient Status Life Support://VAD Brand2:

Patient Status Life Support://VAD Brand1:
Patient Status Life Support:VAD Brand1//Specify:

Patient Status Life Support://VAD Brand2:
Patient Status Life Support:VAD Brand2//Specify:

Patient Status Life Support:VAD Brand1//Specify:
Patient Status Functional Status:

Patient Status Life Support:VAD Brand2//Specify:
Patient Status Working for income:

Patient Status Functional Status:
Patient Status Previous Transplant//Organ Display Only - Cascades from Database
Patient Status Cognitive Development:
Patient Status Previous Transplant//Date Display Only - Cascades from Database
Patient Status Motor Development:
Patient Status Previous Transplant//Graft Fail Date Display Only - Cascades from Database
Patient Status Academic Progress:
Source of Payment Source of Payment//Primary:

Patient Status Academic Activity Level:
Source of Payment Foreign Government//Specify:

Patient Status Previous Transplant//Organ Display Only - Cascades from Database
Clinical Information Height in cm://Height:

Patient Status Previous Transplant//Date Display Only - Cascades from Database
Clinical Information Height Status//ST= Value or status is reported, not both
Patient Status Previous Transplant//Graft Fail Date Display Only - Cascades from Database
Clinical Information Height Growth percentiles//%ile Calculated for display only
Source of Payment Source of Payment//Primary:
Clinical Information Weight in kg://Weight:
Source of Payment Foreign Government//Specify:
Clinical Information Weight Status//ST= Value or status is reported, not both
Clinical Information Height Measurement Date:
Clinical Information Weight Growth percentiles//%ile Calculated for display only
Clinical Information Height in cm://Height:
Clinical Information BMI: Display Only - Cascades from Database
Clinical Information Height Status//ST= Value or status is reported, not both
Clinical Information BMI://%ile Calculated for display only
Clinical Information Height Growth percentiles//%ile Calculated for display only
Clinical Information ABO Blood Group: Display Only - Cascades from Waitlist
Clinical Information Weight Measurement Date:
Clinical Information Primary Diagnosis:

Clinical Information Weight in kg://Weight:
Clinical Information Primary Diagnosis//Specify:

Clinical Information Weight Status//ST= Value or status is reported, not both
General Medical Factors Diabetes:

Clinical Information Weight Growth percentiles//%ile Calculated for display only
General Medical Factors Any previous Malignancy:

Clinical Information BMI: Display Only - Cascades from Database
General Medical Factors Any previous Malignancy//Specify Type:

Clinical Information BMI://%ile Calculated for display only
General Medical Factors Any previous Malignancy//Specify:

Clinical Information ABO Blood Group: Display Only - Cascades from Waitlist
Heart Medical Factors Implantable Defibrillator:

Clinical Information Primary Diagnosis:
Heart Medical Factors Exercise Oxygen Consumption:

Clinical Information Primary Diagnosis//Specify:
Heart Medical Factors Exercise Oxygen Consumption//ST= Value or status is reported, not both
General Medical Factors Diabetes:
Lung Medical Factors Pan-Resistant Bacterial Lung Infection:

General Medical Factors Any previous Malignancy:
Heart/Lung Medical Factors PA (sys) mm/Hg:

General Medical Factors Any previous Malignancy//Specify Type:
Heart/Lung Medical Factors PA (sys) mm/Hg//ST= Value or status is reported, not both
General Medical Factors Any previous Malignancy//Specify:
Heart/Lung Medical Factors PA (sys) mm/Hg Inotropes/Vasodilators

General Medical Factors Total Serum Albumin:
Heart/Lung Medical Factors PA (dia) mm/Hg:

General Medical Factors Total Serum Albumin//ST= Value or status is reported, not both
Heart/Lung Medical Factors PA (dia) mm/Hg//ST= Value or status is reported, not both
Heart Medical Factors Sudden Death:
Heart/Lung Medical Factors PA (dia) mm/Hg Inotropes/Vasodilators

Heart Medical Factors Implantable Defibrillator:
Heart/Lung Medical Factors PA (mean) mm/Hg:

Heart Medical Factors Exercise Oxygen Consumption:
Heart/Lung Medical Factors PA (mean) mm/Hg//ST= Value or status is reported, not both
Heart Medical Factors Exercise Oxygen Consumption//ST= Value or status is reported, not both
Heart/Lung Medical Factors PA (mean) mm/Hg Inotropes/Vasodilators

Lung Medical Factors Pan-Resistant Bacterial Lung Infection:
Heart/Lung Medical Factors PCW (mean) mm/Hg:

Heart/Lung Medical Factors PA (sys) mm/Hg:
Heart/Lung Medical Factors PCW (mean) mm/Hg//ST= Value or status is reported, not both
Heart/Lung Medical Factors PA (sys) mm/Hg//ST= Value or status is reported, not both
Heart/Lung Medical Factors PCW (mean) mm/Hg Inotropes/Vasodilators

Heart/Lung Medical Factors PA (sys) mm/Hg Inotropes/Vasodilators
Heart/Lung Medical Factors CO L/min:

Heart/Lung Medical Factors PA (dia) mm/Hg:
Heart/Lung Medical Factors CO L/min//ST= Value or status is reported, not both
Heart/Lung Medical Factors PA (dia) mm/Hg//ST= Value or status is reported, not both
Heart/Lung Medical Factors CO L/min Inotropes/Vasodilators

Heart/Lung Medical Factors PA (dia) mm/Hg Inotropes/Vasodilators
Heart/Lung Medical Factors History of Cigarette Use:

Heart/Lung Medical Factors PA (mean) mm/Hg:
Heart/Lung Medical Condition Duration of Abstinence:

Heart/Lung Medical Factors PA (mean) mm/Hg//ST= Value or status is reported, not both
Heart/Lung Medical Condition Prior Cardiac Surgery (non-transplant):

Heart/Lung Medical Factors PA (mean) mm/Hg Inotropes/Vasodilators
Heart/Lung Medical Condition If yes, check all that apply:

Heart/Lung Medical Factors PCW (mean) mm/Hg:
Heart/Lung Medical Condition Prior Cardiac Surgery type//Specify:

Heart/Lung Medical Factors PCW (mean) mm/Hg//ST= Value or status is reported, not both




Heart/Lung Medical Factors PCW (mean) mm/Hg Inotropes/Vasodilators



Heart/Lung Medical Factors CO L/min:




Heart/Lung Medical Factors CO L/min//ST= Value or status is reported, not both
PUBLIC BURDEN STATEMENT:


Heart/Lung Medical Factors CO L/min Inotropes/Vasodilators
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].


Heart/Lung Medical Factors History of Cigarette Use:

Heart/Lung Medical Condition Duration of Abstinence:

Heart/Lung Medical Condition Prior Thoracic Surgery other than prior transplant:

Heart/Lung Medical Condition Prior Thoracic Surgery//If yes, number of prior sternotomies:

Heart/Lung Medical Condition Prior Thoracic Surgery//If yes, number of prior thoracotomies:

Heart/Lung Medical Condition Prior Thoracic Surgery//Prior congenital cardiac surgery:

Heart/Lung Medical Condition Prior congenital cardiac surgery//If yes, palliative surgery:

Heart/Lung Medical Condition Prior congenital cardiac surgery//If yes, corrective surgery:

Heart/Lung Medical Condition Prior congenital cardiac surgery//If yes, single ventricular physiology:












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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