25 Liver Transplant Recipient Registration_Form_clean.xlsx

Data System for Organ Procurement and Transplantation Network

Liver Transplant Recipient Registration_Form_clean.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRR - Liver - Adults

TRR - Liver - Pediatrics
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 Surgeon Name
Provider Information Surgeon Name
Provider Information NPI#
Provider Information NPI#
Donor Information UNOS Donor ID # Display Only - Cascades from feedback
Donor Information UNOS Donor ID # Display Only - Cascades from feedback
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 Patient on Life Support
Patient Status Medical Condition at time of transplant
Patient Status Ventilator
Patient Status Patient on Life Support
Patient Status Artificial Liver
Patient Status Ventilator
Patient Status Other Mechanism
Patient Status Artificial Liver
Patient Status Other Mechanism, Specify
Patient Status Other Mechanism
Patient Status Functional Status
Patient Status Other Mechanism, Specify
Patient Status Working for income
Patient Status Functional Status
Patient Status Primary Source of Payment
Patient Status Working for income
Patient Status Primary Source of Payment, Specify
Patient Status Academic Progress
Pretransplant Height
Patient Status Academic Activity Level
Pretransplant Height in Centimeters//Status Value or status is reported, not both
Patient Status Primary Source of Payment
Pretransplant Height Percentile//Growth Percentiles//%ile Calculated for display only
Patient Status Primary Source of Payment, Specify
Pretransplant Weight
Patient Status Cognitive Development
Pretransplant Weight in Kilograms//Status Value or status is reported, not both
Patient Status Motor Development
Pretransplant Weight Percentile//Growth Percentiles//%ile Calculated for display only
Pretransplant Date of Measurement
Pretransplant BMI Display Only - Cascades from Database
Pretransplant Height
Pretransplant BMI://%ile Calculated for display only
Pretransplant Height in Centimeters//Status Value or status is reported, not both
Pretransplant Previous Transplant Organ Display Only - Cascades from Database
Pretransplant Height Percentile//Growth Percentiles//%ile Calculated for display only
Pretransplant Previous Transplant Date Display Only - Cascades from Database
Pretransplant Weight
Pretransplant Previous Transplant Graft Fail Date Display Only - Cascades from Database
Pretransplant Weight in Kilograms//Status Value or status is reported, not both
Pretransplant HIV Serostatus
Pretransplant Weight Percentile//Growth Percentiles//%ile Calculated for display only
Pretransplant NAT HIV

Pretransplant BMI Display Only - Cascades from Database
Pretransplant CMV Status

Pretransplant BMI://%ile Calculated for display only
Pretransplant HBV Core Antibody
Pretransplant Previous Transplant Organ Display Only - Cascades from Database
Pretransplant HBV Surface Antibody Total

Pretransplant Previous Transplant Date Display Only - Cascades from Database
Pretransplant HBV Core Antibody
Pretransplant Previous Transplant Graft Fail Date Display Only - Cascades from Database
Pretransplant HBV Surface Antigen
Pretransplant HIV Serostatus
Pretransplant NAT HBV

Pretransplant NAT HIV
Pretransplant HCV Serostatus
Pretransplant CMV Status
Pretransplant NAT HCV

Pretransplant HBV Core Antibody
Pretransplant EBV Serostatus
Pretransplant HBV Surface Antibody Total
Pretransplant Did the recipient receive Hepatitis B vaccines prior to transplant?

Pretransplant HBV Core Antibody
Pretransplant Has the recipient ever had a diagnosis of HCC?

Pretransplant HBV Surface Antigen
Transplant Procedure Multiple Organ Recipient Display Only - Cascades from feedback
Pretransplant NAT HBV
Transplant Procedure Were extra vessels used in the transplant procedure Display Only - Cascades from feedback
Pretransplant HCV Serostatus
Transplant Procedure Procedure Type Display Only - Cascades from feedback
Pretransplant NAT HCV
Transplant Procedure Split Type
Pretransplant EBV Serostatus
Transplant Procedure Total Cold Ischemia Time (if pumped, include pump time)
Pretransplant Did the recipient receive Hepatitis B vaccines prior to transplant?
Transplant Procedure Total Cold Ischemia Time (if pumped, include pump time)://Status Value or status is reported, not both
Pretransplant Has the recipient ever had a diagnosis of HCC?
Transplant Procedure Previous Abdominal Surgery
Transplant Procedure Multiple Organ Recipient Display Only - Cascades from feedback
Transplant Procedure Portal Vein Thrombosis
Transplant Procedure Were extra vessels used in the transplant procedure Display Only - Cascades from feedback
Transplant Procedure Transjugular Intrahepatic Portacaval Stint Shunt
Transplant Procedure Procedure Type Display Only - Cascades from feedback
Post Transplant Pathology Conf. Liver Diag. of Hospital Discharge
Transplant Procedure Split Type
Post Transplant If Other Pathology Conf. Liver Diag. of Hospital Discharge//Specify
Transplant Procedure Total Cold Ischemia Time (if pumped, include pump time)
Post Transplant Graft Status
Transplant Procedure Total Cold Ischemia Time (if pumped, include pump time)://Status Value or status is reported, not both
Post Transplant Date of Graft Failure
Transplant Procedure Previous Abdominal Surgery
Post Transplant Primary Non-Function
Transplant Procedure Portal Vein Thrombosis
Post Transplant Hepatic Artery Thrombosis

Transplant Procedure Transjugular Intrahepatic Portacaval Stint Shunt
Post Transplant Other Vascular Thrombosis
Post Transplant Pathology Conf. Liver Diag. of Hospital Discharge
Post Transplant Hepatic outflow obstruction
Post Transplant If Other Pathology Conf. Liver Diag. of Hospital Discharge//Specify
Post Transplant Portal vein thrombosis
Post Transplant Graft Status
Post Transplant Diffuse Cholangiopathy

Post Transplant Date of Graft Failure
Post Transplant Hepatitis: DeNovo
Post Transplant Primary Non-Function
Post Transplant Hepatitis: Recurrent
Post Transplant Hepatic Artery Thrombosis
Post Transplant Recurrent Disease (non-Hepatitis)
Post Transplant Other Vascular Thrombosis
Post Transplant Acute Rejection
Post Transplant Hepatic outflow obstruction
Post Transplant Infection
Post Transplant Portal vein thrombosis
Post Transplant Other, Specify
Post Transplant Diffuse Cholangiopathy
Post Transplant Did patient have any acute rejection episodes between transplant and discharge
Post Transplant Hepatitis: DeNovo
Immunosuppression Other Are any medications given currently for maintenance or anti-rejection
Post Transplant Hepatitis: Recurrent
Immunosuppression Other Immunosuppression medication

Post Transplant Recurrent Disease (non-Hepatitis)
Immunosuppression Other Immunosuppression medication indication

Post Transplant Acute Rejection
Immunosuppression Other Days of induction

Post Transplant Infection




Post Transplant Other, Specify



Post Transplant Did patient have any acute rejection episodes between transplant and discharge
PUBLIC BURDEN STATEMENT:

Immunosuppression Other Are any medications given currently for maintenance or anti-rejection
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].


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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