51 VCA Transplant Recipient Registration_Form_clean.xlsx

Data System for Organ Procurement and Transplantation Network

VCA Transplant Recipient Registration_Form_clean.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRR - VCA - Adult/Pediatric
Fields to be completed by members






Form Section Field Label Notes
Recipient Information Recipient First Name Display Only - Cascades from Removal Worksheet
Recipient Information Recipient Last Name Display Only - Cascades from Removal Worksheet
Recipient Information Recipient Middle Initial Display Only - Cascades from Removal Worksheet
Recipient Information DOB Display Only - Cascades from Removal Worksheet
Recipient Information SSN Display Only - Cascades from Removal Worksheet
Recipient Information Gender Display Only - Cascades from Removal Worksheet
Recipient Information HIC
Recipient Information Transplant Date Display Only - Cascades from Removal Worksheet
Recipient Information State of Permanent Residence
Recipient Information Permanent Zip Code
Provider Information Recipient Center Display Only - Cascades from Removal Worksheet
Provider Information Lead Reconstructive Surgeon Name
Provider Information Lead Reconstructive Surgeon NPI#
Donor Information UNOS Donor ID # Display Only - Cascades from Removal Worksheet
Donor Information Donor Type Display Only - Cascades from Removal Worksheet
Donor Information OPO Display Only - Cascades from Removal Worksheet
Patient Status - Transplant hospitalization Date of Admission to Transplant Center
Patient Status - Transplant hospitalization Date of Discharge from Hospital
Patient Status Date Last Seen, Retransplanted, or Death
Patient Status Patient Status
Patient Status Primary Cause of Death
Patient Status Primary Cause of Death - Other Specify
Socio-Demographic Information: Pre-Transplant Highest Education Level
Socio-Demographic Information: Pre-Transplant Working for income
Socio-Demographic Information: Pre-Transplant Working for income - If Yes, indicate the recipient's working status
Socio-Demographic Information: Pre-Transplant Working for income - If No, Not Working Due To
Socio-Demographic Information: Pre-Transplant - Source of Payment Grant Funding
Socio-Demographic Information: Pre-Transplant - Source of Payment Institutional Funding
Socio-Demographic Information: Pre-Transplant - Source of Payment Primary Source of Payment
Socio-Demographic Information: Pre-Transplant - Source of Payment Primary Source of Payment - Foreign Government, Specify
Socio-Demographic Information: Pre-Transplant - Source of Payment Secondary Source of Payment
Clinical Information: Pre-transplant Height (inches)
Clinical Information: Pre-transplant Weight (lbs.)
Clinical Information: Pre-transplant BMI (Body Mass Index) Display Only - Calculated
Clinical Information: Pre-transplant Primary Diagnosis for Transplant
Clinical Information: Pre-transplant Primary Diagnosis for Transplant - Other Specify
Clinical Information: Pre-transplant - Amount of Tissue Loss Craniofacial
Clinical Information: Pre-transplant - Amount of Tissue Loss Craniofacial - Partial Face - Specify anatomic structures missing
Clinical Information: Pre-transplant - Amount of Tissue Loss Craniofacial - Other Specify
Clinical Information: Pre-transplant - Amount of Tissue Loss Abdominal Wall (cm2)
Clinical Information: Pre-transplant - Amount of Tissue Loss Other VCA Organ Type - Other Specify
Clinical Information: Pre-transplant - Level of Amputation Upper Limb, Left
Clinical Information: Pre-transplant - Level of Amputation Upper Limb, Left - Other Specify
Clinical Information: Pre-transplant - Level of Amputation Upper Limb, Right
Clinical Information: Pre-transplant - Level of Amputation Upper Limb, Right - Other Specify
Clinical Information: Pre-transplant - Level of Amputation Lower Limb, Left
Clinical Information: Pre-transplant - Level of Amputation Lower Limb, Left - Other Specify
Clinical Information: Pre-transplant - Level of Amputation Lower Limb, Right
Clinical Information: Pre-transplant - Level of Amputation Lower Limb, Right - Other Specify
Clinical Information: Pre-transplant Previous Transplants (VCA or non-VCA organs)
Clinical Information: Pre-transplant Previous skin graft(s)
Clinical Information: Pre-transplant Was patient hospitalized during the last 90 days prior to the transplant admission
Clinical Information: Pre-transplant Medical condition at time of transplant
Clinical Information: Pre-transplant Patient on Life Support
Clinical Information: Pre-transplant Patient on Life Support - Ventilator
Clinical Information: Pre-transplant Patient on Life Support - Other Mechanism
Clinical Information: Pre-transplant Patient on Life Support - Other Mechanism - Other Specify
Clinical Information: Pre-transplant - Viral Detection HIV Serostatus
Clinical Information: Pre-transplant - Viral Detection CMV Status
Clinical Information: Pre-transplant - Viral Detection HBV Core Antibody
Clinical Information: Pre-transplant - Viral Detection HBV Surface Antigen
Clinical Information: Pre-transplant - Viral Detection HCV Serostatus
Clinical Information: Pre-transplant - Viral Detection EBV Serostatus
Clinical Information: Pre-transplant - Viral Detection Did the recipient receive Hepatitis B vaccines prior to transplant?
Clinical Information: Pre-transplant Any tolerance induction technique used
Clinical Information: Pre-transplant Pre-transplant blood transfusions
Clinical Information: Pre-transplant Number of pre-transplant pregnancies (which may or may not have resulted in a live birth)
Clinical Information: Pre-transplant Malignancies prior to transplant
Clinical Information: Pre-transplant Malignancies prior to transplant - If Yes, Specify Type (select all that apply)
Clinical Information: Pre-transplant - Pre-Transplant Labs Serum Creatinine (mg/dL)
Clinical Information: Pre-transplant - Pre-Transplant Labs Hemoglobin A1c (%)
Clinical Information: Pre-transplant - Pre-Transplant Labs Calculated PRA (CPRA) at transplant (%)
Clinical Information: Pre-transplant - Pre-Transplant Labs Donor Crossmatch Result
Clinical Information: Pre-transplant - Risk Factors Coagulopathies
Clinical Information: Pre-transplant - Risk Factors Other Risk Factors
Clinical Information: Pre-transplant - Risk Factors Other Risk Factors - Other Specify
Functional Status: Pre-transplant Cognitive Development
Functional Status: Pre-transplant Motor Development
Functional Status: Pre-transplant - SF-36 score - Physical Health Physical Functioning (PF) score
Functional Status: Pre-transplant - SF-36 score - Physical Health Role-Physical (RP) score
Functional Status: Pre-transplant - SF-36 score - Physical Health Bodily Pain (BP) score
Functional Status: Pre-transplant - SF-36 score - Physical Health General Health (GH) score
Functional Status: Pre-transplant - SF-36 score - Mental Health Vitality (VT) score
Functional Status: Pre-transplant - SF-36 score - Mental Health Social Functioning (SF) score
Functional Status: Pre-transplant - SF-36 score - Mental Health Role-Emotional (RE) score
Functional Status: Pre-transplant - SF-36 score - Mental Health Mental Heath (MH) score
Functional Status: Pre-transplant - Upper Limb - Pre-Transplant DASH Score
Functional Status: Pre-transplant - Upper Limb - Pre-Transplant Carroll Test Score - Left
Functional Status: Pre-transplant - Upper Limb - Pre-Transplant Carroll Test Score - Right
Clinical Information: Transplant Procedure Multiple Graft Recipient
Clinical Information: Transplant Procedure Were extra allograft vessels/nerve/tissue from outside the donated graft used in the transplant procedure
Clinical Information: Transplant Procedure Surgical Procedure Display Only - Cascades from Removal Worksheet
Clinical Information: Transplant Procedure - Preservation Information Warm Ischemia Time (include anastomotic time)
Clinical Information: Transplant Procedure - Preservation Information Cold Ischemia Time
Clinical Information: Post Transplant Graft Status
Clinical Information: Post Transplant Date of Graft Failure
Clinical Information: Post Transplant - Causes of Graft Failure Thrombosis
Clinical Information: Post Transplant - Causes of Graft Failure Acute Rejection
Clinical Information: Post Transplant - Causes of Graft Failure Acute Rejection - Banff score
Clinical Information: Post Transplant - Causes of Graft Failure Acute Rejection - Visual skin changes
Clinical Information: Post Transplant - Causes of Graft Failure Chronic Rejection
Clinical Information: Post Transplant - Causes of Graft Failure Chronic Rejection - Visual skin changes
Clinical Information: Post Transplant - Causes of Graft Failure Ischemia
Clinical Information: Post Transplant - Causes of Graft Failure Sepsis / Infection
Clinical Information: Post Transplant - Causes of Graft Failure Trauma
Clinical Information: Post Transplant - Causes of Graft Failure Patient requested removal
Clinical Information: Post Transplant - Causes of Graft Failure Non-compliance: immunosuppression
Clinical Information: Post Transplant - Causes of Graft Failure Non-compliance: rehabilitation
Clinical Information: Post Transplant - Causes of Graft Failure Non-compliance: level of activity
Clinical Information: Post Transplant - Causes of Graft Failure Other
Clinical Information: Post Transplant - Causes of Graft Failure Other - Other Specify
Clinical Information: Post Transplant - Discharge Lab Data Serum Creatinine (mg/dL)
Clinical Information: Post Transplant - Discharge Lab Data Hemoglobin A1c (%)
Clinical Information: Post Transplant - Major Transplant Complication Arterial Thrombosis
Clinical Information: Post Transplant - Major Transplant Complication Venous Thrombosis
Clinical Information: Post Transplant - Major Transplant Complication More than 5 pRBC (packed red blood cells) units
Clinical Information: Post Transplant - Major Transplant Complication Cardiac arrest
Clinical Information: Post Transplant - Major Transplant Complication DIC (Disseminated intravascular coagulation)
Clinical Information: Post Transplant - Major Transplant Complication Graft/reperfusion syndrome
Clinical Information: Post Transplant - Major Transplant Complication Other Major Transplant Complications
Clinical Information: Post Transplant - Major Transplant Complication Other Major Transplant Complications - Other Specify
Clinical Information: Post Transplant Did patient have any acute rejection episodes between transplant and discharge
Clinical Information: Post Transplant Did patient have any acute rejection episodes between transplant and discharge - Number of episodes
Clinical Information: Post Transplant {For each episode} Date of acute rejection diagnosis
Clinical Information: Post Transplant {For each episode} Acute rejection was treated
Clinical Information: Post Transplant {For each episode} Visual skin changes
Clinical Information: Post Transplant {For each episode} Biopsy was done to confirm acute rejection
Clinical Information: Post Transplant {For each episode} Banff Score
Treatment Antiviral Prophylaxis
Treatment Antibacterial Prophylaxis
Treatment Antifungal Prophylaxis
Treatment Peri-operative anticoagulation
Topical Immunosuppressive Medications Immunosuppression medications
Topical Immunosuppressive Medications Immunosuppression medications - Other Specify
Topical Immunosuppressive Medications Maintenance indication
Topical Immunosuppressive Medications Anti-rejection indication
Non-Topical Immunosuppressive Medications Immunosuppression medications
Non-Topical Immunosuppressive Medications Immunosuppression medications - Other Specify
Non-Topical Immunosuppressive Medications Induction indication
Non-Topical Immunosuppressive Medications Number of days of induction
Non-Topical Immunosuppressive Medications Maintenance indication
Non-Topical Immunosuppressive Medications Anti-rejection 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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