33 Liver Transplant Recipient Follow Up Post 5 Year_Form.xl

Data System for Organ Procurement and Transplantation Network

Liver Transplant Recipient Follow Up Post 5 Year_Form.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRF (Post 5-Year) - Liver - Adult

TRF (Post 5-Year) - Liver - 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 Type Display Only - Cascades from Database
Recipient Information Organ Type Display Only - Cascades from Database
Recipient Information Follow-up code 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 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 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 SSN Display Only - Cascades from TCR
Recipient Information HIC 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 Follow-up Display Only - Cascades from prior TRF
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 Database
Recipient Information Tx Date Display Only - Cascades from Database
Recipient Information Previous Px Stat Date 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 Transplant Discharge Date
Recipient Information State of Permanent Residence
Recipient Information State of Permanent Residence
Recipient Information Zip Code
Recipient Information Zip Code
Provider Information Recipient Center Display Only - Cascades from TCR
Provider Information Recipient Center 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 Follow-up Center Code Display Only - Cascades from Database
Provider Information Follow-up Center Code Display Only - Cascades from Database
Provider Information Follow-up Center Type 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 UNOS Donor ID # Display Only - Cascades from Database
Donor Information Donor Type Display Only - Cascades from Database
Donor Information Donor Type Display Only - Cascades from Database
Donor Information OPO Display Only - Cascades from feedback
Donor Information OPO Display Only - Cascades from feedback
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 Primary Cause of Death//Specify
Patient Status Primary Cause of Death//Specify
Clinical Information Graft Status
Patient Status Functional Status
Clinical Information Date of Failure
Patient Status Cognitive Development
Clinical Information Primary Non-Function
Patient Status Motor Development
Clinical Information Hepatic Artery Thrombosis
Clinical Information Date of Measurement
Clinical Information Other Vascular Thrombosis
Clinical Information Height
Clinical Information Hepatic Outflow Obstruction
Clinical Information Height//Status Value or status is reported, not both
Clinical Information Portal Vein Thrombosis
Clinical Information Height Percentile Calculated for display only
Clinical Information Diffuse Cholangiopathy
Clinical Information Weight
Clinical Information Hepatitis: DeNovo
Clinical Information Weight//Status Value or status is reported, not both
Clinical Information Hepatitis: Recurrent
Clinical Information Weight Percentile Calculated for display only
Clinical Information Recurrent Disease (non-Hepatitis)
Clinical Information BMI Display Only - Cascades from Database
Clinical Information Acute Rejection
Clinical Information BMI Calculated for display only
Clinical Information Infection

Clinical Information Graft Status
Clinical Information Other, Specify

Clinical Information Date of Failure
Clinical Information Most Recent Serum Creatinine
Clinical Information Primary Non-Function
Clinical Information Most Recent Serum Creatinine://Status Value or status is reported, not both
Clinical Information Hepatic Artery Thrombosis
Clinical Information Post Transplant Malignancy
Clinical Information Other Vascular Thrombosis
Clinical Information Donor Related
Clinical Information Hepatic Outflow Obstruction
Clinical Information Recurrence of Pre-Tx Tumor
Clinical Information Portal Vein Thrombosis
Clinical Information De Novo Solid Tumor
Clinical Information Diffuse Cholangiopathy
Clinical Information De Novo Lymphoproliferative disease and Lymphoma
Clinical Information Hepatitis: DeNovo




Clinical Information Hepatitis: Recurrent



Clinical Information Recurrent Disease (non-Hepatitis)




Clinical Information Acute Rejection
PUBLIC BURDEN STATEMENT:

Clinical Information Infection
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].


Clinical Information Other, Specify

Clinical Information Most Recent Serum Creatinine

Clinical Information Most Recent Serum Creatinine://Status Value or status is reported, not both

Clinical Information New diabetes onset between last follow-up to the current follow-up

Clinical Information Insulin dependent

Clinical Information Coronary Artery Disease Since Last Follow-up

Clinical Information Post Transplant Malignancy

Clinical Information Donor Related

Clinical Information Recurrence of Pre-Tx Tumor

Clinical Information De Novo Solid Tumor

Clinical Information De Novo Lymphoproliferative disease and Lymphoma















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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