41 Pancreas Transplant Recipient Registration_Form_clean.xl

Data System for Organ Procurement and Transplantation Network

Pancreas Transplant Recipient Registration_Form_clean.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
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].





























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