31 Intestine Transplant Recipient Registration_Form_clean.x

TRR - Intestine - Adult					TRR - Intestine - 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	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	Secondary Diagnosis	Not required		Patient Status	Secondary Diagnosis	Not required
Patient Status	Secondary Diagnosis//Specify	Not required		Patient Status	Secondary Diagnosis//Specify	Not required
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	Not required		Patient Status	Date of Discharge from Tx Center	Not required
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	Ventilator			Patient Status	Ventilator
Patient Status	Artificial Liver			Patient Status	Artificial Liver
Patient Status	Other Mechanism			Patient Status	Other Mechanism
Patient Status	Other Mechanism, Specify			Patient Status	Other Mechanism, Specify
Patient Status	Functional Status			Patient Status	Functional Status
Patient Status	Working for income			Patient Status	Academic Progress
Patient Status	Primary Source of Payment			Patient Status	Academic Activity Level
Patient Status	Primary Source of Payment, Specify			Patient Status	Primary Source of Payment
Pretransplant	Height			Patient Status	Primary Source of Payment, Specify
Pretransplant	Height in Centimeters//Status	Value or status is reported, not both		Patient Status	Cognitive Development
Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		Patient Status	Motor Development
Pretransplant	Weight			Pretransplant	Date of Measurement
Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both		Pretransplant	Height
Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only		Pretransplant	Height in Centimeters//Status	Value or status is reported, not both
Pretransplant	BMI	Display Only - Cascades from Database		Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only
Pretransplant	BMI://%ile	Calculated for display only		Pretransplant	Weight
Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database		Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both
Pretransplant	Previous Transplant Date	Display Only - Cascades from Database		Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		Pretransplant	BMI	Display Only - Cascades from Database
Pretransplant	HIV Serostatus			Pretransplant	BMI://%ile	Calculated for display only
Pretransplant	NAT HIV			Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database
Pretransplant	CMV Status			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 Antibody Total			Pretransplant	HIV Serostatus
Pretransplant	HBV Surface Antigen			Pretransplant	NAT HIV
Pretransplant	NAT HBV			Pretransplant	CMV Status
Pretransplant	HCV Serostatus			Pretransplant	HBV Core Antibody
Pretransplant	NAT HCV			Pretransplant	HBV Surface Antibody Total
Pretransplant	EBV Serostatus			Pretransplant	HBV Surface Antigen
Pretransplant	Did the recipient receive Hepatitis B vaccines prior to transplant?			Pretransplant	NAT HBV
Pretransplant	Total Bilirubin			Pretransplant	HCV Serostatus
Pretransplant	Total Bilirubin//Status	Value or status is reported, not both		Pretransplant	NAT HCV
Pretransplant	Serum Albumin			Pretransplant	EBV Serostatus
Pretransplant	Serum Albumin//Status	Value or status is reported, not both		Pretransplant	Did the recipient receive Hepatitis B vaccines prior to transplant?
Pretransplant	Serum Creatinine			Pretransplant	Total Bilirubin
Pretransplant	Serum Creatinine//Status	Value or status is reported, not both		Pretransplant	Total Bilirubin//Status	Value or status is reported, not both
Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		Pretransplant	Serum Albumin
Transplant Procedure	Intestine Venous Drainage			Pretransplant	Serum Albumin//Status	Value or status is reported, not both
Transplant Procedure	Native Viscera Venous Drainage			Pretransplant	Serum Creatinine
Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		Pretransplant	Serum Creatinine//Status	Value or status is reported, not both
Transplant Procedure	Stomach			Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
Transplant Procedure	Small Intestine			Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
Transplant Procedure	Duodenum			Transplant Procedure	Intestine Venous Drainage
Transplant Procedure	Large Intestine			Transplant Procedure	Native Viscera Venous Drainage
Transplant Procedure	Total Ischemic Time (include cold, warm and anastomotic time)			Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
Transplant Procedure	Total ischemia Time Hours (include cold, warm and anastomotic time)//Status	Value or status is reported, not both		Transplant Procedure	Stomach
Transplant Procedure	Recent Septicemia			Transplant Procedure	Small Intestine
Transplant Procedure	Exhausted Vascular Access			Transplant Procedure	Duodenum
Transplant Procedure	Previous Abdominal Surgery			Transplant Procedure	Large Intestine
Transplant Procedure	Dilated/Non-Functional Bowel Segments			Transplant Procedure	Total Ischemic Time (include cold, warm and anastomotic time)
Transplant Procedure	Other risk factors	Not required		Transplant Procedure	Total ischemia Time Hours (include cold, warm and anastomotic time)//Status	Value or status is reported, not both
Post Transplant	Graft Status			Transplant Procedure	Recent Septicemia
Post Transplant	TPN Dependent			Transplant Procedure	Exhausted Vascular Access
Post Transplant	IV Dependent			Transplant Procedure	Previous Abdominal Surgery
Post Transplant	Oral Feeding			Transplant Procedure	Dilated/Non-Functional Bowel Segments
Post Transplant	Tube Feed			Transplant Procedure	Other risk factors	Not required
Post Transplant	Date of Graft Failure			Post Transplant	Graft Status
Post Transplant	Primary Cause of Graft Failure			Post Transplant	TPN Dependent
Post Transplant	Primary Cause of Graft Failure//Specify			Post Transplant	IV Dependent
Post Transplant	Did patient have any acute rejection episodes between transplant and discharge			Post Transplant	Oral Feeding
Immunosuppression Other	Are any medications given currently for maintenance or anti-rejection			Post Transplant	Tube Feed
Immunosuppression Other	Immunosuppression medication			Post Transplant	Date of Graft Failure
Immunosuppression Other	Immunosuppression medication indication			Post Transplant	Primary Cause of Graft Failure
Immunosuppression Other	Days of induction			Post Transplant	Primary Cause of Graft Failure//Specify
				Post Transplant	Did patient have any acute rejection episodes between transplant and discharge
				Immunosuppression Other	Are any medications given currently for maintenance or anti-rejection
				Immunosuppression Other	Immunosuppression medication
PUBLIC BURDEN STATEMENT:				Immunosuppression Other	Immunosuppression medication indication
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	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].