41 Pancreas Transplant Recipient Registration_Form_clean.xl

TRR - Pancreas - Adult					TRR - Pancreas - 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	Cognitive Development
Patient Status	Primary Source of Payment			Patient Status	Motor Development
Patient Status	Specify Foreign Government//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	Specify Foreign Government//Specify
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	If Yes, Date First Dialyzed//Status	Value or status is reported, not both		Pretransplant	Previous Transplant Date	Display Only - Cascades from Database
Pretransplant	Average Daily Insulin Units			Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
Pretransplant	Average Daily Insulin Units//Status	Value or status is reported, not both		Pretransplant	Pretransplant Dialysis
Pretransplant	Serum Creatinine at Time of Tx			Pretransplant	If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis
Pretransplant	Serum Creatinine at Time of Tx//Status	Value or status is reported, not both		Pretransplant	If Yes, Date First Dialyzed//Status	Value or status is reported, not both
Pretransplant	HIV Serostatus			Pretransplant	Average Daily Insulin Units
Pretransplant	NAT HIV			Pretransplant	Average Daily Insulin Units//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 Surface Antigen
Pretransplant	Did the recipient receive Hepatitis B vaccines prior to transplant?			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	Malignancies between listing and transplant//Specify
Transplant Procedure	Graft Placement			Pretransplant	If yes, specify type
Transplant Procedure	Operative Technique			Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
Transplant Procedure	Duct Management			Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
Transplant Procedure	Duct Management//Specify			Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
Transplant Procedure	Venous Vascular Management			Transplant Procedure	Graft Placement
Transplant Procedure	Arterial Reconstruction			Transplant Procedure	Operative Technique
Transplant Procedure	Arterial Reconstruction//Specify			Transplant Procedure	Duct Management
Transplant Procedure	Venous Extension Graft			Transplant Procedure	Duct Management//Specify
Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)			Transplant Procedure	Venous Vascular Management
Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)//Status	Value or status is reported, not both		Transplant Procedure	Arterial Reconstruction
Post Transplant	Pancreas Graft Status			Transplant Procedure	Arterial Reconstruction//Specify
Post Transplant	Patient using any method of blood sugar control?			Transplant Procedure	Venous Extension Graft
Post Transplant	Patient on insulin?	New field if pancreas graft status is functioning. Modified label if graft status is failed		Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)
Post Transplant	Date insulin resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed		Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)//Status	Value or status is reported, not both
Post Transplant	Total insulin dosage units			Post Transplant	Pancreas Graft Status
Post Transplant	Total insulin dosage units//ST	Value or status is reported, not both		Post Transplant	Patient using any method of blood sugar control?
Post Transplant	Insulin duration of use			Post Transplant	Patient on insulin?	New field if pancreas graft status is functioning. Modified label if graft status is failed
Post Transplant	Insulin duration of use//ST	Value or status is reported, not both		Post Transplant	Date insulin resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed
Post Transplant	Patient on oral medication to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed		Post Transplant	Total insulin dosage units
Post Transplant	Date oral medications resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed		Post Transplant	Total insulin dosage units//ST	Value or status is reported, not both
Post Transplant	Patient using diet to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed		Post Transplant	Insulin duration of use
Post Transplant	Date of Graft Failure			Post Transplant	Insulin duration of use//ST	Value or status is reported, not both
Post Transplant	C-Peptide Value			Post Transplant	Patient on oral medication to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed
Post Transplant	C-Peptide Value://ST=	Value or status is reported, not both		Post Transplant	Date oral medications resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed
Post Transplant	Hba1c (%)			Post Transplant	Patient using diet to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed
Post Transplant	Hba1c (%)//Status	Value or status is reported, not both		Post Transplant	Date of Graft Failure
Post Transplant	Pancreas Primary Cause of Graft Failure			Post Transplant	C-Peptide Value
Post Transplant	Pancreas Primary Cause of Graft Failure//Specify			Post Transplant	C-Peptide Value://ST=	Value or status is reported, not both
Post Transplant	Pancreas Graft/Vascular Thrombosis			Post Transplant	Hba1c (%)
Post Transplant	Pancreas Infection			Post Transplant	Hba1c (%)//Status	Value or status is reported, not both
Post Transplant	Bleeding			Post Transplant	Pancreas Primary Cause of Graft Failure
Post Transplant	Anastomotic Leak			Post Transplant	Pancreas Primary Cause of Graft Failure//Specify
Post Transplant	Hyperacute Rejection			Post Transplant	Pancreas Graft/Vascular Thrombosis
Post Transplant	Pancreas Acute Rejection			Post Transplant	Pancreas Infection
Post Transplant	Biopsy Proven Isletitis			Post Transplant	Bleeding
Post Transplant	Pancreatitis			Post Transplant	Anastomotic Leak
Post Transplant	Other, Specify			Post Transplant	Hyperacute Rejection
Post Transplant	Pancreatitis			Post Transplant	Pancreas Acute Rejection
Post Transplant	Anastomotic Leak			Post Transplant	Biopsy Proven Isletitis
Post Transplant	Abscess or Local Infection			Post Transplant	Pancreatitis
Post Transplant	Pancreas Transplant Complications: Other	Not required		Post Transplant	Other, Specify
Post Transplant	Did patient have any acute rejection episodes between transplant and discharge			Post Transplant	Pancreatitis
Immunosuppression Other	Are any medications given currently for maintenance or anti-rejection			Post Transplant	Anastomotic Leak
Immunosuppression Other	Immunosuppression medication			Post Transplant	Abscess or Local Infection
Immunosuppression Other	Immunosuppression medication indication			Post Transplant	Pancreas Transplant Complications: Other	Not required
Immunosuppression Other	Days of induction			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].