47 Kidney/Pancreas Transplant Recipient Follow Up 6 Month_5

Data System for Organ Procurement and Transplantation Network

KidneyPancreas Transplant Recipient Follow Up 6 Month_5 Year_Form.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRF (6 Month - 5 Year) - Kidney/Pancreas - Adult

TRF (6 Month - 5 Year) - Kidney/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 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
Provider Information Physician Name
Provider Information Physician Name
Provider Information NPI#
Provider Information NPI#
Provider Information Follow-up Care Provided By
Provider Information Follow-up Care Provided By
Provider Information Follow-up Care Provided By//Specify
Provider Information Follow-up Care Provided By//Specify
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 If Retransplanted, choose organ(s)
Patient Status If Retransplanted, choose organ(s)
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
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 Has the patient been hospitalized since the last patient status date
Patient Status Has the patient been hospitalized since the last patient status date
Patient Status Functional Status
Patient Status Functional Status
Patient Status Working for income
Patient Status at Time of Follow-up Cognitive Development
Patient Status Primary Insurance at Follow-up
Patient Status at Time of Follow-up Motor Development
Patient Status Primary Source of Payment, Specify
Patient Status Working for income
Clinical Information Weight
Patient Status Academic Progress
Clinical Information Weight//Status Value or status is reported, not both
Patient Status Academic Activity Level
Clinical Information HIV Serology

Patient Status Primary Insurance at Follow-up
Clinical Information HIV NAT

Patient Status Primary Source of Payment, Specify
Clinical Information HbsAg

Clinical Information Date of Measurement
Clinical Information HBV DNA

Clinical Information Height
Clinical Information HBV Core Antibody

Clinical Information Height//Status Value or status is reported, not both
Clinical Information HCV Serology

Clinical Information Height Percentile Calculated for display only
Clinical Information HCV NAT

Clinical Information Weight
Clinical Information Graft Status
Clinical Information Weight//Status Value or status is reported, not both
Clinical Information If Functioning, Most Recent Serum Creatinine
Clinical Information Weight Percentile Calculated for display only
Clinical Information If Functioning, Most Recent Serum Creatinine://Status Value or status is reported, not both
Clinical Information BMI Display Only - Cascades from Database
Clinical Information Date of Graft Failure:

Clinical Information BMI Calculated for display only
Clinical Information Primary Cause of Graft Failure:

Clinical Information Graft Status
Clinical Information Primary Cause of Graft Failure//Other, Specify:

Clinical Information If Functioning, Most Recent Serum Creatinine
Clinical Information Dialysis Since Last Follow-up
Clinical Information If Functioning, Most Recent Serum Creatinine://Status Value or status is reported, not both
Clinical Information Date Maintenance Dialysis Resumed
Clinical Information Date of Graft Failure:
Clinical Information Pancreas Graft Status
Clinical Information Primary Cause of Graft Failure:
Clinical Information Patient on insulin? New field if pancreas graft status is functioning. Modified label if graft status is failed
Clinical Information Primary Cause of Graft Failure//Other, Specify:
Clinical Information Date insulin resumed New field if pancreas graft status is functioning. Modified label if graft status is failed
Clinical Information Dialysis Since Last Follow-up
Clinical Information Total insulin dosage units

Clinical Information Date Maintenance Dialysis Resumed
Clinical Information Total insulin dosage units//ST Value or status is reported, not both
Clinical Information Pancreas Graft Status
Clinical Information Insulin duration of use

Clinical Information Patient on insulin? New field if pancreas graft status is functioning. Modified label if graft status is failed
Clinical Information Insulin duration of use//ST Value or status is reported, not both
Clinical Information Date insulin resumed New field if pancreas graft status is functioning. Modified label if graft status is failed
Clinical Information Patient on oral medication to control blood sugar New field if pancreas graft status is functioning. Modified label if graft status is failed
Clinical Information Total insulin dosage units
Clinical Information Date oral medications resumed New field if pancreas graft status is functioning. Modified label if graft status is failed
Clinical Information Total insulin dosage units//ST Value or status is reported, not both
Clinical Information Patient using diet to control blood sugar New field if pancreas graft status is functioning. Modified label if graft status is failed
Clinical Information Insulin duration of use
Clinical Information Pancreas Date of Failure

Clinical Information Insulin duration of use//ST Value or status is reported, not both
Clinical Information C-Peptide Value

Clinical Information Patient on oral medication to control blood sugar New field if pancreas graft status is functioning. Modified label if graft status is failed
Clinical Information C-Peptide Value://ST= Value or status is reported, not both
Clinical Information Date oral medications resumed New field if pancreas graft status is functioning. Modified label if graft status is failed
Clinical Information Hba1c (%)

Clinical Information Patient using diet to control blood sugar New field if pancreas graft status is functioning. Modified label if graft status is failed
Clinical Information Hba1c (%)//Status Value or status is reported, not both
Clinical Information Pancreas Date of Failure
Clinical Information Pancreas Primary Causes of Graft Failure
Clinical Information C-Peptide Value
Clinical Information Specify
Clinical Information C-Peptide Value://ST= Value or status is reported, not both
Clinical Information Pancreas Graft/Vascular Thrombosis
Clinical Information Hba1c (%)
Clinical Information Pancreas Infection
Clinical Information Hba1c (%)//Status Value or status is reported, not both
Clinical Information Pancreas Bleeding
Clinical Information Pancreas Primary Causes of Graft Failure
Clinical Information Anastomotic Leak
Clinical Information Specify
Clinical Information Pancreas Rejection: Acute
Clinical Information Pancreas Graft/Vascular Thrombosis
Clinical Information Pancreas Chronic Rejection
Clinical Information Pancreas Infection
Clinical Information Biopsy Proven Isletitis
Clinical Information Pancreas Bleeding
Clinical Information Pancreatitis
Clinical Information Anastomotic Leak
Clinical Information Patient Noncompliance
Clinical Information Pancreas Rejection: Acute
Clinical Information Other, Specify
Clinical Information Pancreas Chronic Rejection
Clinical Information Conv. From Bladder to Enteric Drain Performed
Clinical Information Biopsy Proven Isletitis
Clinical Information Enteric Drain Date
Clinical Information Pancreatitis
Clinical Information Pancreas Transplant Complications (Not leading to graft failure) Display Only - Cascades from Database
Clinical Information Patient Noncompliance
Clinical Information Pancreatitis
Clinical Information Other, Specify
Clinical Information Anastomotic Leak
Clinical Information HIV Serology
Clinical Information Abscess or Local Infection
Clinical Information HIV NAT
Clinical Information Did patient have any kidney acute rejection episodes during the follow-up period
Clinical Information HbsAg
Clinical Information Did patient have any pancreas acute rejection episodes during the follow-up period:

Clinical Information HBV DNA
Clinical Information Post Transplant Malignancy
Clinical Information HBV Core Antibody
Clinical Information Donor Related
Clinical Information HCV Serology
Clinical Information Recurrence of Pre-Tx Tumor
Clinical Information HCV NAT
Clinical Information De Novo Solid Tumor
Clinical Information Conv. From Bladder to Enteric Drain Performed
Clinical Information De Novo Lymphoproliferative disease and Lymphoma
Clinical Information Enteric Drain Date
Clinical Information Were any medications given during the follow-up period for maintenance
Clinical Information Pancreas Transplant Complications (Not leading to graft failure)
Immunosuppressive Information Previous Validated Maintenance Follow-up Medications Display Only - Cascades from Database
Clinical Information Pancreatitis
Immunosuppressive Information Immunosuppression medication

Clinical Information Anastomotic Leak
Immunosuppressive Information Immunosuppression medication indication

Clinical Information Abscess or Local Infection




Clinical Information Did patient have any kidney acute rejection episodes during the follow-up period Value or status is reported, not both




Clinical Information Did patient have any pancreas acute rejection episodes during the follow-up period:
PUBLIC BURDEN STATEMENT:


Clinical Information Is growth hormone therapy used during this follow-up period
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 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

Clinical Information Fracture in the past year (or since last follow-up)

Clinical Information Specify Location and number of fractures

Clinical Information Spine-compression fracture

Clinical Information Specify Location and number of fractures

Clinical Information Extremity

Clinical Information Specify Location and number of fractures

Clinical Information Other

Clinical Information AVN (avascular necrosis) Display Only - Cascades from Database

Immunosuppressive Information Were any medications given during the follow-up period for maintenance Display Only - Cascades from Database




Immunosuppressive Information Previous Validated Maintenance Follow-up Medications




Immunosuppressive Information Immunosuppression medication




Immunosuppressive Information Immunosuppression medication indication
























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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