19 Heart/Lung Transplant Recipient Registration_Form_clean.

TRR - Heart/Lung - Adult					TRR - 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
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	Other Mechanism			Patient Status	Prostaglandins
Patient Status	Other Mechanism, Specify			Patient Status	Intravenous Inotropes
Patient Status	Prostacyclin Infusion			Patient Status	Ventilator
Patient Status	Prostacyclin Inhalation			Patient Status	Inhaled NO
Patient Status	Patient on Ventricular Assist Device			Patient Status	Other Mechanism
Patient Status	Life Support: VAD Brand1			Patient Status	Other Mechanism, Specify
Patient Status	Life Support: VAD Brand1//Specify			Patient Status	Prostacyclin Infusion
Patient Status	Life Support: VAD Brand2			Patient Status	Prostacyclin Inhalation
Patient Status	Life Support: VAD Brand2//Specify			Patient Status	Patient on Ventricular Assist Device
Patient Status	Functional Status			Patient Status	Life Support: VAD Brand1
Patient Status	Working for income			Patient Status	Life Support: VAD Brand1//Specify
Patient Status	Primary Source of Payment			Patient Status	Life Support: VAD Brand2
Patient Status	Primary Source of Payment, Specify			Patient Status	Life Support: VAD Brand2//Specify
Pretransplant	Height			Patient Status	Functional Status
Pretransplant	Height in Centimeters//Status	Value or status is reported, not both		Patient Status	Academic Progress
Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		Patient Status	Academic Activity Level
Pretransplant	Weight			Patient Status	Primary Source of Payment
Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both		Patient Status	Primary Source of Payment, Specify
Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only		Patient Status	Cognitive Development
Pretransplant	BMI	Display Only - Cascades from Database		Patient Status	Motor Development
Pretransplant	BMI://%ile	Calculated for display only		Pretransplant	Height Measurement Date
Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database		Pretransplant	Height
Pretransplant	Previous Transplant Date	Display Only - Cascades from Database		Pretransplant	Height in Centimeters//Status	Value or status is reported, not both
Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only
Pretransplant	HIV Serostatus			Pretransplant	Weight Measurement Date
Pretransplant	NAT HIV			Pretransplant	Weight
Pretransplant	CMV Status			Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both
Pretransplant	HBV Core Antibody			Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
Pretransplant	HBV Surface Antibody Total			Pretransplant	BMI	Display Only - Cascades from Database
Pretransplant	HBV Surface Antigen			Pretransplant	BMI://%ile	Calculated for display only
Pretransplant	NAT HBV			Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database
Pretransplant	HCV Serostatus			Pretransplant	Previous Transplant Date	Display Only - Cascades from Database
Pretransplant	NAT HCV			Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
Pretransplant	EBV Serostatus			Pretransplant	HIV Serostatus
Pretransplant	Did the recipient receive Hepatitis B vaccines prior to transplant?			Pretransplant	NAT HIV
Pretransplant	PA (sys)mm/Hg			Pretransplant	CMV Status
Pretransplant	PA (sys)mm/Hg//Status	Value or status is reported, not both		Pretransplant	HBV Core Antibody
Pretransplant	PA(sys)mm/Hg Inotropes/VASODilators			Pretransplant	HBV Surface Antibody Total
Pretransplant	PA(dia) mm/Hg			Pretransplant	HBV Surface Antigen
Pretransplant	PA(dia) mm/HG//Status	Value or status is reported, not both		Pretransplant	NAT HBV
Pretransplant	PA (dia) mm/Hg Inotropes/Vasodilators			Pretransplant	HCV Serostatus
Pretransplant	PA(mean) mm/Hg			Pretransplant	NAT HCV
Pretransplant	PA(mean) mm/Hg//Status	Value or status is reported, not both		Pretransplant	EBV Serostatus
Pretransplant	PA (mean) mm/Hg Inotropes/Vasodilators			Pretransplant	Did the recipient receive Hepatitis B vaccines prior to transplant?
Pretransplant	PCW(mean) mm/Hg			Pretransplant	PA (sys)mm/Hg
Pretransplant	PCW(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	PCW (mean) mm/Hg Inotropes/Vasodilators			Pretransplant	PA(sys)mm/Hg Inotropes/VASODilators
Pretransplant	CO L/min			Pretransplant	PA(dia) mm/Hg
Pretransplant	CO L/min//Status	Value or status is reported, not both		Pretransplant	PA(dia) mm/HG//Status	Value or status is reported, not both
Pretransplant	CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators			Pretransplant	PA (dia) mm/Hg Inotropes/Vasodilators
Pretransplant	Most Recent Serum Creatinine			Pretransplant	PA(mean) mm/Hg
Pretransplant	Most Recent Serum Creatinine//Status	Value or status is reported, not both		Pretransplant	PA(mean) mm/Hg//Status	Value or status is reported, not both
Pretransplant	Most Recent Total Bilirubin			Pretransplant	PA (mean) mm/Hg Inotropes/Vasodilators
Pretransplant	Most Recent Total Bilirubin//Status	Value or status is reported, not both		Pretransplant	PCW(mean) mm/Hg
Pretransplant	Chronic Steroid Use			Pretransplant	PCW(mean) mm/Hg//Status	Value or status is reported, not both
Pretransplant	FVC			Pretransplant	PCW (mean) mm/Hg Inotropes/Vasodilators
Pretransplant	FVC % predicted//Status	Value or status is reported, not both		Pretransplant	CO L/min
Pretransplant	FeV1			Pretransplant	CO L/min//Status	Value or status is reported, not both
Pretransplant	FeV1 % predicted//Status	Value or status is reported, not both		Pretransplant	CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators
Pretransplant	pCO2			Pretransplant	Cardiac Index	Display Only - Cascades from Database
Pretransplant	pCO2 mm/Hg//Status	Value or status is reported, not both		Pretransplant	Most Recent Serum Creatinine
Pretransplant	Transfusions			Pretransplant	Most Recent Serum Creatinine//Status	Value or status is reported, not both
Pretransplant	Infection Requiring IV Therapy within 2 wks prior to Tx			Pretransplant	Most Recent Total Bilirubin
Pretransplant	Dialysis			Pretransplant	Most Recent Total Bilirubin//Status	Value or status is reported, not both
Pretransplant	Prior Cardiac Surgery (non-transplant)			Pretransplant	Chronic Steroid Use
Pretransplant	If yes, check all that apply			Pretransplant	FVC
Pretransplant	Prior Cardiac Surgery//Specify			Pretransplant	FVC % predicted//Status	Value or status is reported, not both
Pretransplant	Prior Lung Surgery (non-transplant)			Pretransplant	FeV1
Pretransplant	If yes, check all that apply			Pretransplant	FeV1 % predicted//Status	Value or status is reported, not both
Pretransplant	Prior Lung Surgery//Specify			Pretransplant	pCO2
Pretransplant	Episode of Ventilatory Support			Pretransplant	pCO2 mm/Hg//Status	Value or status is reported, not both
Pretransplant	If yes, indicate most recent timeframe			Pretransplant	Transfusions
Pretransplant	Tracheostomy			Pretransplant	Infection Requiring IV Therapy within 2 wks prior to Tx
Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		Pretransplant	Dialysis
Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback		Pretransplant	Episode of Ventilatory Support
Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		Pretransplant	If yes, indicate most recent timeframe
Transplant Procedure	Heart Procedure			Pretransplant	Tracheostomy
Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Heart, Heart-Lung			Pretransplant	Prior Thoracic Surgery other than prior transplant
Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time)://Status	Value or status is reported, not both		Pretransplant	If yes, number of prior sternotomies
Transplant Procedure	Lung(s) perfused prior to transplant?			Pretransplant	If yes, number of prior thoracotomies
Transplant Procedure	Perfusion occurred at:			Pretransplant	Prior congenital cardiac surgery
Transplant Procedure	Perfusion performed by:			Pretransplant	If yes, palliative surgery
Transplant Procedure	Total time on perfusion			Pretransplant	If yes, corrective surgery
Transplant Procedure	Lung(s) received at transplant center			Pretransplant	If yes, single ventricular physiology
Transplant Procedure	On ice			Pretransplant	Most Recent Anti-A Titer
Transplant Procedure	On pump			Pretransplant	Most Recent Anti-A Titer//Sample Date
Transplant Procedure	Right Lung/Enbloc: Stayed on pump Put on ice Left Lung: Stayed on pump Put on ice			Pretransplant	Most Recent Anti-B Titer
Post Transplant	Graft Status			Pretransplant	Most Recent Anti-B Titer//Sample Date
Post Transplant	Date of Graft Failure			Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
Post Transplant	Primary Cause of Graft Failure			Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
Post Transplant	Primary Cause of Graft Failure// Other Specify			Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
Post Transplant	Stroke			Transplant Procedure	Heart Procedure
Post Transplant	Dialysis			Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Heart, Heart-Lung
Post Transplant	Ventilator Support			Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time)://Status	Value or status is reported, not both
Post Transplant	Reintubated			Transplant Procedure	Lung(s) perfused prior to transplant?
Post Transplant	Permanent Pacemaker			Transplant Procedure	Perfusion occurred at:
Post Transplant	Airway Dehiscence			Transplant Procedure	Perfusion performed by:
Post Transplant	Did patient have any acute rejection episodes between transplant and discharge			Transplant Procedure	Total time on perfusion
Post Transplant	Intubated at 72 hours			Transplant Procedure	Lung(s) received at transplant center
Post Transplant	PaO2 at 72 hours			Transplant Procedure	On ice
Post Transplant	PaO2 at 72 hours//Status	Value or status is reported, not both		Transplant Procedure	On pump
Post Transplant	FiO2 at 72 hours			Transplant Procedure	Right Lung/Enbloc: Stayed on pump Put on ice Left Lung: Stayed on pump Put on ice
Post Transplant	FiO2 at 72 hours//Status	Value or status is reported, not both		Post Transplant	Graft Status
Post Transplant	ECMO a 72 hours			Post Transplant	Date of Graft Failure
Post Transplant	Inhaled NO at 72 hours			Post Transplant	Primary Cause of Graft Failure
Immunosuppression Other	Are any medications given currently for maintenance or anti-rejection			Post Transplant	Primary Cause of Graft Failure// Other Specify
Immunosuppression Other	Immunosuppression medication			Post Transplant	Ventilator Support
Immunosuppression Other	Immunosuppression medication indication			Post Transplant	Reintubated
Immunosuppression Other	Days of induction			Post Transplant	Permanent Pacemaker
				Post Transplant	Airway Dehiscence
				Post Transplant	Did patient have any acute rejection episodes between transplant and discharge
				Post Transplant	Intubated at 72 hours
PUBLIC BURDEN STATEMENT:				Post Transplant	PaO2 at 72 hours
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	PaO2 at 72 hours//Status	Value or status is reported, not both
				Post Transplant	FiO2 at 72 hours
				Post Transplant	FiO2 at 72 hours//Status	Value or status is reported, not both
				Post Transplant	ECMO a 72 hours
				Post Transplant	Inhaled NO at 72 hours
				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
				Post Transplant	Stroke
				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].