31 Intestine Transplant Recipient Registration_Form_clean.x

Data System for Organ Procurement and Transplantation Network

Intestine Transplant Recipient Registration_Form_clean.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
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].





























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