36 Kidney Transplant Recipient Registration_Form_clean.xlsx

Data System for Organ Procurement and Transplantation Network

Kidney Transplant Recipient Registration_Form_clean.xlsx

Kidney Transplant Recipient Registration (TRR)

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRR - Kidney - Adult

TRR - Kidney - 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 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 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 Specify Foreign Government//Specify
Patient Status Primary Source of Payment
Pretransplant Height
Patient Status Specify Foreign Government//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 Pretransplant Dialysis
Pretransplant BMI://%ile Calculated for display only
Pretransplant If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis
Pretransplant Previous Transplant Organ Display Only - Cascades from Database
Pretransplant Date First Dialyzed//Status Value or status is reported, not both
Pretransplant Previous Transplant Date Display Only - Cascades from Database
Pretransplant Serum Creatinine at Time of Tx
Pretransplant Previous Transplant Graft Fail Date Display Only - Cascades from Database
Pretransplant Serum Creatinine at Time of Tx//Status Value or status is reported, not both
Pretransplant Pretransplant Dialysis
Pretransplant HIV Serostatus
Pretransplant If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis
Pretransplant NAT HIV

Pretransplant Date First Dialyzed//Status Value or status is reported, not both
Pretransplant CMV Status

Pretransplant Serum Creatinine at Time of Tx
Pretransplant HBV Core Antibody
Pretransplant Serum Creatinine at Time of Tx//Status Value or status is reported, not both
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 Core Antibody
Pretransplant Did the recipient receive Hepatitis B vaccines prior to transplant?

Pretransplant HBV Surface Antigen
Pretransplant Previous Pregnancies
Pretransplant NAT HBV
Pretransplant Malignancies between listing and transplant
Pretransplant HCV Serostatus
Pretransplant If yes, specify type
Pretransplant NAT HCV
Pretransplant Malignancies between listing and transplant//Specify
Pretransplant EBV Serostatus
Transplant Procedure Multiple Organ Recipient Display Only - Cascades from feedback
Pretransplant Did the recipient receive Hepatitis B vaccines prior to transplant?
Transplant Procedure Were extra vessels used in the transplant procedure Display Only - Cascades from feedback
Pretransplant Malignancies between listing and transplant
Transplant Procedure Procedure Type Display Only - Cascades from feedback
Pretransplant If yes, specify type
Transplant Procedure Total Cold ischemia Time Right KI(OR EN-BLOC): (if pumped, include pump time)
Pretransplant Malignancies between listing and transplant//Specify
Transplant Procedure Total Cold Ischemia Time//Status Value or status is reported, not both
Pretransplant Fracture in the past year (or since last follow-up)
Transplant Procedure Total Cold ischemia Time Left KI (if pumped, include pump time)
Pretransplant Spine-compression fracture
Transplant Procedure Total Cold Ischemia Time//Status Value or status is reported, not both
Pretransplant Spine-compression fracture//# of fractures
Transplant Procedure Kidney(s) received on
Pretransplant Extremity
Transplant Procedure Received on ice
Pretransplant Extremity//# of fractures
Transplant Procedure Received on pump
Pretransplant Other
Transplant Procedure Left Kidney Final resistance at transplant
Pretransplant Other//# of fractures
Transplant Procedure Left Kidney Final resistance at tx//Status Value or status is reported, not both
Pretransplant AVN (avascular necrosis)
Transplant Procedure Right Kidney Final resistance at transplant

Transplant Procedure Multiple Organ Recipient Display Only - Cascades from feedback
Transplant Procedure Right Kidney Final resistance at tx//Status Value or status is reported, not both
Transplant Procedure Were extra vessels used in the transplant procedure Display Only - Cascades from feedback
Transplant Procedure Left Kidney Final flow rate at transplant
Transplant Procedure Procedure Type Display Only - Cascades from feedback
Transplant Procedure Left Kidney Final flow rate at tx//Status Value or status is reported, not both
Transplant Procedure Total Cold ischemia Time Right KI(OR EN-BLOC): (if pumped, include pump time)
Transplant Procedure Right Kidney Final flow rate at transplant

Transplant Procedure Total Cold Ischemia Time//Status Value or status is reported, not both
Transplant Procedure Right Kidney Final flow rate at tx//Status Value or status is reported, not both
Transplant Procedure Total Cold ischemia Time Left KI (if pumped, include pump time)
Post Transplant Graft Status
Transplant Procedure Total Cold Ischemia Time//Status Value or status is reported, not both
Post Transplant Date of Graft Failure:

Transplant Procedure Kidney(s) received on
Post Transplant Primary Cause of Graft Failure:

Transplant Procedure Received on ice
Post Transplant Primary Cause of Graft Failure//Other, Specify:

Transplant Procedure Received on pump
Post Transplant Resumed Maintenance Dialysis
Transplant Procedure Left Kidney Final resistance at transplant
Post Transplant Date Maintenance Dialysis Resumed
Transplant Procedure Left Kidney Final resistance at tx//Status Value or status is reported, not both
Post Transplant Most Recent Serum Creatinine Prior to Discharge
Transplant Procedure Right Kidney Final resistance at transplant
Post Transplant Most Recent Serum Creatinine Prior to Disch.//Status Value or status is reported, not both
Transplant Procedure Right Kidney Final resistance at tx//Status Value or status is reported, not both
Post Transplant Patient Need Dialysis within First Week
Transplant Procedure Left Kidney Final flow rate at transplant
Post Transplant Did patient have any acute rejection episodes between transplant and discharge
Transplant Procedure Left Kidney Final flow rate at tx//Status Value or status is reported, not both
Immunosuppression Other Are any medications given currently for maintenance or anti-rejection
Transplant Procedure Right Kidney Final flow rate at transplant
Immunosuppression Other Immunosuppression medication

Transplant Procedure Right Kidney Final flow rate at tx//Status Value or status is reported, not both
Immunosuppression Other Immunosuppression medication indication

Post Transplant Graft Status
Immunosuppression Other Days of induction

Post Transplant Date of Graft Failure:




Post Transplant Primary Cause of Graft Failure:



Post Transplant Primary Cause of Graft Failure//Other, Specify:




Post Transplant Resumed Maintenance Dialysis
PUBLIC BURDEN STATEMENT:

Post Transplant Date Maintenance Dialysis Resumed
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].


Post Transplant Most Recent Serum Creatinine Prior to Discharge

Post Transplant Most Recent Serum Creatinine Prior to Disch.//Status Value or status is reported, not both

Post Transplant Patient Need Dialysis within First Week

Post Transplant Did patient have any acute rejection episodes between transplant and discharge

Pretransplant Is growth hormone therapy used between listing and transplant

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

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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