52 VCA Transplant Recipient Follow Up_Form.xlsx

Data System for Organ Procurement and Transplantation Network

VCA Transplant Recipient Follow Up_Form.xlsx

VCA Transplant Recipient Follow Up (TRF)

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TRF - 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 Display Only - Cascades from TRR
Recipient Information Transplant Date Display Only - Cascades from Removal Worksheet
Recipient Information State of Permanent Residence
Recipient Information Permanent zip code
Provider Information Treating Reconstructive Surgeon Name
Provider Information Treating Reconstructive Surgeon NPI#
Provider Information Treating Transplant Physician Name
Provider Information Treating Transplant Physician NPI#
Provider Information Follow-up Care Provided By:
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 Date Last Seen, Retransplanted, or Death
Patient Status Patient Status
Patient Status Primary Cause of Death
Patient Status Primary Cause of Death - Other Specify
Patient Status Has patient been hospitalized since the Last Patient Status Date
Patient Status Number of Hospitalizations
Socio-Demographic Information Working for income
Socio-Demographic Information Working for income - If Yes, indicate the recipient's working status
Socio-Demographic Information Working for income - If No, Not Working Due To
Socio-Demographic Information - Source of Payment Grant funding
Socio-Demographic Information - Source of Payment Institutional funding
Socio-Demographic Information - Source of Payment Primary Source of Payment
Socio-Demographic Information - Source of Payment Primary Source of Payment - Foreign Government, Specify
Socio-Demographic Information - Source of Payment Secondary Source of Payment
Functional Status Cognitive Development
Functional Status Motor Development
Functional Status Psychosocial consult performed
Functional Status - SF-36 score - Physical Health Physical Functioning (PF) score
Functional Status - SF-36 score - Physical Health Role-Physical (RP) score
Functional Status - SF-36 score - Physical Health Bodily Pain (BP) score
Functional Status - SF-36 score - Physical Health General Health (GH) score
Functional Status - SF-36 score - Mental Health Vitality (VT) score
Functional Status - SF-36 score - Mental Health Social Functioning (SF) score
Functional Status - SF-36 score - Mental Health Role-Emotional (RE) score
Functional Status - SF-36 score - Mental Health Mental Heath (MH) score
Functional Status - Upper Limb DASH Score
Functional Status - Upper Limb Carroll Test Score - Left
Functional Status - Upper Limb Carroll Test Score - Right
Functional Status - Upper Limb Sensibility Test - Semmes Weinstein - Left
Functional Status - Upper Limb Sensibility Test - Semmes Weinstein - Right
Functional Status - Craniofacial Olfactory function restored
Functional Status - Craniofacial - Sensory Testing 2 point discrimination (mm)
Functional Status - Craniofacial - Sensory Testing - Hot/cold testing Can feel heat
Functional Status - Craniofacial - Sensory Testing - Hot/cold testing Can feel cold
Functional Status - Craniofacial - Motor function Oral competence
Functional Status - Craniofacial - Motor function Corneal protection
Functional Status - Craniofacial Functional occlusion restored
Functional Status - Craniofacial Decannulation (if the patient had a tracheostomy)
Functional Status - Craniofacial Feeding Tube Removed (if the patient had a feeding tube to start with)
Functional Status - Craniofacial - Speech Intelligibility Tests Speaking rate
Functional Status - Craniofacial - Speech Intelligibility Tests Percent Intelligibility
Clinical Information Height (inches)
Clinical Information Weight (lbs.)
Clinical Information BMI (Body Mass Index) Display Only - Calculated
Clinical Information - Noncompliance Immunosuppression
Clinical Information - Noncompliance Rehabilitation
Clinical Information - Noncompliance Level of Activity
Clinical Information - Noncompliance Other
Clinical Information - Noncompliance Other - Other Specify
Clinical Information Graft Status
Clinical Information Date of Graft Failure
Clinical Information - Causes of Graft Failure Acute Rejection
Clinical Information - Causes of Graft Failure Acute Rejection - Banff score
Clinical Information - Causes of Graft Failure Acute Rejection - Visual skin changes
Clinical Information - Causes of Graft Failure Chronic Rejection
Clinical Information - Causes of Graft Failure Chronic Rejection - Visual skin changes
Clinical Information - Causes of Graft Failure Ischemia
Clinical Information - Causes of Graft Failure Sepsis / Infection
Clinical Information - Causes of Graft Failure Trauma
Clinical Information - Causes of Graft Failure Patient requested removal
Clinical Information - Causes of Graft Failure Non-compliance: immunosuppression
Clinical Information - Causes of Graft Failure Non-compliance: rehabilitation
Clinical Information - Causes of Graft Failure Non-compliance: level of activity
Clinical Information - Causes of Graft Failure Other
Clinical Information - Causes of Graft Failure Other - Other Specify
Clinical Information - Most Recent Lab Data Serum Creatinine (mg/dL)
Clinical Information - Most Recent Lab Data Hemoglobin A1c (%)
Clinical Information - Most Recent Lab Data Donor Specific Antibodies (DSA)
Clinical Information Did patient have any acute rejection episodes during the follow-up period
Clinical Information Did patient have any acute rejection episodes during the follow-up period - Number of episodes
Clinical Information {For each episode} Date of acute rejection diagnosis
Clinical Information {For each episode} Acute rejection was treated
Clinical Information {For each episode} Visual skin changes
Clinical Information {For each episode} Biopsy was done to confirm acute rejection
Clinical Information {For each episode} Banff Score
Clinical Information - Complications New onset diabetes
Clinical Information - Complications Metabolic Complications
Clinical Information - Complications Infectious Complications
Clinical Information - Complications Other Complications
Clinical Information - Complications Other Complications - Other Specify
Clinical Information Post Transplant Malignancy
Clinical Information - Post-transplant Malignancy Donor Related
Clinical Information - Post-transplant Malignancy - Donor Related Diagnosis date:
Clinical Information - Post-transplant Malignancy - Donor Related Tumor type
Clinical Information - Post-transplant Malignancy Recurrence of Pre-Tx Tumor
Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy Date of recurrence
Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy Type of pre-existing tumor
Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy Type of pre-existing tumor - Other, Specify
Clinical Information - Post-transplant Malignancy De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Diagnosis date
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: Skin: //squamous cell:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: Skin: //basal cell:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: Skin: //melanoma:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Kaposi's sarcoma: cutaneous:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Kaposi's sarcoma: visceral:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Brain:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: Brain: //Other specify:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Renal carcinoma - specify site(s):
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Carcinoma of vulva, perineum or penis, scrotum:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Carcinoma of the uterus:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Ovarian:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Testicular:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Esophagus:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Stomach:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Small intestine:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Pancreas:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Larynx:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Tongue, throat:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Thyroid:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Bladder:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Breast:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Prostate:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Colo-rectal:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Primary hepatic tumor:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Metastatic liver tumor:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Lung:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types://Leukemia:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Sarcomas:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Other cancers:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Other Cancers: //Site(s):
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor Tumor Types: //Primary unknown:
Clinical Information - Post-transplant Malignancy De Novo Lymphoproliferative disease and Lymphoma
Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma PTLD: //Diagnosis date:
Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma PTLD: //Pathology:
Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma PTLD: Pathology: //Other Specify:
Treatment Antiviral
Treatment Antibiotic
Treatment Antifungal
Topical Immunosuppressive Medications Immunosuppression medications
Topical Immunosuppressive Medications Immunosuppression medications - Other Specify
Topical Immunosuppressive Medications Previous maintenance indication
Topical Immunosuppressive Medications Current 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 Previous maintenance indication
Non-Topical Immunosuppressive Medications Current 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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