20 Heart/Lung Transplant Recipient Follow Up 6 Month_Form.x

Data System for Organ Procurement and Transplantation Network

HeartLung Transplant Recipient Follow Up 6 Month_Form.xlsx

Heart/Lung Transplant Recipient Follow Up 6 Month (TRF)

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRF (6-Month) - Heart/Lung - Adult and Pediatric
Fields to be completed by members



Form Section Field label Notes
Recipient Information Organ Type 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 Last Name 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 HIC Display Only - Cascades from TCR
Recipient Information Previous Follow-up 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 DOB Display Only - Cascades from TCR
Recipient Information Gender Display Only - Cascades from TCR
Recipient Information Tx Date Display Only - Cascades from Database
Recipient Information State of Permanent Residence
Recipient Information Zip Code
Provider Information Recipient Center Type Display Only - Cascades from TCR
Provider Information Recipient Center Display Only - Cascades from TCR
Provider Information Follow-up Center Code Display Only - Cascades from Database
Provider Information Follow-up Center Type Display Only - Cascades from Database
Donor Information UNOS Donor ID # Display Only - Cascades from Database
Donor Information Donor Type Display Only - Cascades from Database
Donor Information OPO Display Only - Cascades from feedback
Patient Status Date: Last Seen, Retransplanted or Death
Patient Status Patient Status
Patient Status Primary Cause of Death
Patient Status Primary Cause of Death//Specify
Patient Status Contributory Cause of Death 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//Specify Not required
Clinical Information Heart Graft Status
Clinical Information Heart Date of Graft Failure
Clinical Information Heart Primary Cause of Graft Failure
Clinical Information Heart Primary Cause of Graft Failure//Other, Specify
Clinical Information Graft Status
Clinical Information Date of Graft Failure
Clinical Information Primary Cause of Graft Failure
Clinical Information Primary Cause of Graft Failure// Other Specify
Clinical Information Date Test Performed Value or status is reported, not both
Clinical Information FEV1 Value or status is reported, not both
Clinical Information FVC Value or status is reported, not both
Clinical Information FEF 25-75 Value or status is reported, not both
Clinical Information Date Test Performed Value or status is reported, not both
Clinical Information FEV1 Value or status is reported, not both
Clinical Information FVC Value or status is reported, not both
Clinical Information FEF 25-75 Value or status is reported, not both
Clinical Information Date Test Performed Value or status is reported, not both
Clinical Information FEV1 Value or status is reported, not both
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
Clinical Information With exercise: FiO2 or Flow Value or status is reported, not both
Clinical Information HIV Serology
Clinical Information HIV NAT
Clinical Information HbsAg
Clinical Information HBV DNA
Clinical Information HBV Core Antibody
Clinical Information HCV Serology
Clinical Information HCV NAT
Clinical Information Most Recent Anti-A Titer
Clinical Information Most Recent Anti-A Titer//Sample Date
Clinical Information Most Recent Anti-B Titer
Clinical Information Most Recent Anti-B Titer//Sample Date








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].

File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy