19 Heart/Lung Transplant Recipient Registration_Form_clean.

Data System for Organ Procurement and Transplantation Network

HeartLung Transplant Recipient Registration_Form_clean.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
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].





















































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