Document
Kidney_Pancreas
ICR 202202-0915-002 · OMB 0915-0157 · Object 118773901.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | Kidney_Pancreas |
| Author | Windows User |
| Last Modified By | Calc |
| File Modified | 2021-10-28 |
| File Created | 2026-08-25 |
| Conversion State | complete |
Extracted Text
TRF (Post 5-Year) - Kidney/Pancreas - Adult Fields to be completed by members Form Section Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Provider Information Provider Information Provider Information Provider Information Donor Information Donor Information Donor Information Patient Status Patient Status Patient Status Patient Status Patient Status Clinical Information Field Label Organ Type Follow-up code Recipient First Name Recipient Last Name Recipient Middle Initial SSN HIC Previous Follow-up DOB Gender Tx Date Previous Px Stat Date Transplant Discharge Date State of Permanent Residence Zip Code Recipient Center Recipient Center Type Follow-up Center Code Follow-up Center Type UNOS Donor ID # Donor Type OPO Date: Last Seen, Retransplanted or Death Patient Status If Retransplanted, choose organ(s) Primary Cause of Death Primary Cause of Death//Specify Graft Status Clinical Information If Functioning, Most Recent Serum Creatinine Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information If Functioning, Most Recent Serum Creatinine://Status Date of Graft Failure: Primary Cause of Graft Failure: Primary Cause of Graft Failure//Other, Specify: Pancreas Graft Status Pancreas Date of Failure Pancreas Primary Causes of Graft Failure Specify Pancreas Graft/Vascular Thrombosis Pancreas Infection Clinical Information Pancreas Bleeding Clinical Information Clinical Information Clinical Information Anastomotic Leak Pancreas Rejection: Acute Pancreas Chronic Rejection Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Biopsy Proven Isletitis Pancreatitis Patient Noncompliance Other, Specify Post Transplant Malignancy Donor Related Recurrence of Pre-Tx Tumor De Novo Solid Tumor De Novo Lymphoproliferative disease and Lymphoma Notes Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from prior TRF Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from Database Display Only - Cascades from prior TRF Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from feedback Value or status is reported, not both 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]. 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]. TRF (Post 5-Year) - Kidney/Pancreas - Pediatric Fields to be completed by members Form Section Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Provider Information Provider Information Provider Information Provider Information Donor Information Donor Information Donor Information Patient Status Patient Status Patient Status Patient Status Patient Status Patient Status Patient Status at Time of Follow-up Patient Status at Time of Follow-up Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Field Label Organ Type Follow-up code Recipient First Name Recipient Last Name Recipient Middle Initial SSN HIC Previous Follow-up DOB Gender Tx Date Previous Px Stat Date Transplant Discharge Date State of Permanent Residence Zip Code Recipient Center Recipient Center Type Follow-up Center Code Follow-up Center Type UNOS Donor ID # Donor Type OPO Date: Last Seen, Retransplanted or Death Patient Status If Retransplanted, choose organ(s) Primary Cause of Death Primary Cause of Death//Specify Functional Status Notes Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from prior TRF Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from Database Display Only - Cascades from prior TRF Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from feedback Cognitive Development Motor Development Height Height//Status Height Percentile Weight Weight//Status Weight Percentile BMI BMI Graft Status If Functioning, Most Recent Serum Creatinine If Functioning, Most Recent Serum Creatinine://Status Date of Graft Failure: Primary Cause of Graft Failure: Primary Cause of Graft Failure//Other, Specify: Pancreas Graft Status Pancreas Date of Failure Pancreas Primary Causes of Graft Failure Specify Pancreas Graft/Vascular Thrombosis Pancreas Infection Pancreas Bleeding Anastomotic Leak Pancreas Rejection: Acute Pancreas Chronic Rejection Biopsy Proven Isletitis Pancreatitis Patient Noncompliance Other, Specify Coronary Artery Disease Since Last Follow-up Post Transplant Malignancy Donor Related Recurrence of Pre-Tx Tumor De Novo Solid Tumor Value or status is reported, not both Not required Value or status is reported, not both Not required Display Only - Cascades from Database Not required Value or status is reported, not both 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].