6 Heart Transplant Candidate Registration_Form_clean.xlsx

TCR - Heart - Adult				TCR - Heart - Pediatric
Fields to be completed by members				Fields to be completed by members
Form Section	Field Label	Notes		Form Section	Field Label	Notes
Provider Information	Transplant Center Code	Display Only - Cascades from Waitlist		Provider Information	Transplant Center Code	Display Only - Cascades from Waitlist
Provider Information	Transplant Center Type://Recipient Center	Display Only - Cascades from Waitlist		Provider Information	Transplant Center Type://Recipient Center	Display Only - Cascades from Waitlist
Candidate Information	Organ Registered:	Display Only - Cascades from Waitlist		Candidate Information	Organ Registered:	Display Only - Cascades from Waitlist
Candidate Information	Date of Listing or Add:	Display Only - Cascades from Waitlist		Candidate Information	Date of Listing or Add:	Display Only - Cascades from Waitlist
Candidate Information	Last Name:	Cascades from Waitlist		Candidate Information	Last Name:	Cascades from Waitlist
Candidate Information	First Name:	Cascades from Waitlist		Candidate Information	First Name:	Cascades from Waitlist
Candidate Information	Middle Initial://MI:	Not required		Candidate Information	Middle Initial://MI:	Not required
Candidate Information	Previous Surname:	Not required		Candidate Information	Previous Surname:	Not required
Candidate Information	SSN:	Display Only - Cascades from Waitlist		Candidate Information	SSN:	Display Only - Cascades from Waitlist
Candidate Information	Gender:	Cascades from Waitlist		Candidate Information	Gender:	Cascades from Waitlist
Candidate Information	HIC:	Not required		Candidate Information	HIC:	Not required
Candidate Information	Date of Birth://DOB:	Cascades from Waitlist		Candidate Information	Date of Birth://DOB:	Cascades from Waitlist
Candidate Information	State of Permanent Residence:	Cascades from Waitlist		Candidate Information	State of Permanent Residence:	Cascades from Waitlist
Candidate Information	Permanent ZIP Code:	Cascades from Waitlist		Candidate Information	Permanent ZIP Code:	Cascades from Waitlist
Candidate Information	Ethnicity:	Cascades from Waitlist		Candidate Information	Ethnicity:	Cascades from Waitlist
Candidate Information	Race:	Cascades from Waitlist		Candidate Information	Race:	Cascades from Waitlist
Candidate Information	Citizenship:			Candidate Information	Citizenship:
Candidate Information	Year of Entry to the U.S.			Candidate Information	Year of Entry to the U.S.
Candidate Information	Year of Entry to the U.S Status//ST=	Value or status is reported, not both		Candidate Information	Year of Entry to the U.S Status//ST=	Value or status is reported, not both
Candidate Information	Country of Permanent Residence			Candidate Information	Country of Permanent Residence
Candidate Information	Highest Education Level:			Candidate Information	Highest Education Level:
Patient Status	Patient on Life Support:			Patient Status	Patient on Life Support:
Patient Status	Life Support://Extra Corporeal Membrane Oxygenation			Patient Status	Life Support://Extra Corporeal Membrane Oxygenation
Patient Status	Life Support://Intra Aortic Balloon Pump			Patient Status	Life Support://Intra Aortic Balloon Pump
Patient Status	Life Support://Prostaglandins			Patient Status	Life Support://Prostaglandins
Patient Status	Life Support://Intravenous Inotropes			Patient Status	Life Support://Intravenous Inotropes
Patient Status	Life Support://Inhaled NO			Patient Status	Life Support://Inhaled NO
Patient Status	Life Support://Ventilator			Patient Status	Life Support://Ventilator
Patient Status	Life Support://Other Mechanism, Specify			Patient Status	Life Support://Other Mechanism, Specify
Patient Status	Life Support: Other Mechanism//Specify:			Patient Status	Life Support: Other Mechanism//Specify:
Patient Status	Life Support://Patient on Ventricular Assist Device:			Patient Status	Life Support://Patient on Ventricular Assist Device:
Patient Status	Life Support://VAD Brand1:			Patient Status	Life Support://VAD Brand1:
Patient Status	Life Support://VAD Brand2:			Patient Status	Life Support://VAD Brand2:
Patient Status	Life Support:VAD Brand1//Specify:			Patient Status	Life Support:VAD Brand1//Specify:
Patient Status	Life Support:VAD Brand2//Specify:			Patient Status	Life Support:VAD Brand2//Specify:
Patient Status	Functional Status:			Patient Status	Functional Status:
Patient Status	Working for income:			Patient Status	Cognitive Development:
Patient Status	Previous Transplant//Organ	Display Only - Cascades from Database		Patient Status	Motor Development:
Patient Status	Previous Transplant//Date	Display Only - Cascades from Database		Patient Status	Working for income:
Patient Status	Previous Transplant//Graft Fail Date	Display Only - Cascades from Database		Patient Status	Academic Progress:
Source of Payment	Source of Payment//Primary:			Patient Status	Academic Activity Level:
Source of Payment	Foreign Government//Specify:			Patient Status	Previous Transplant//Organ	Display Only - Cascades from Database
Clinical Information	Height in cm://Height:			Patient Status	Previous Transplant//Date	Display Only - Cascades from Database
Clinical Information	Height Status//ST=	Value or status is reported, not both		Patient Status	Previous Transplant//Graft Fail Date	Display Only - Cascades from Database
Clinical Information	Height Growth percentiles//%ile	Calculated for display only		Source of Payment	Source of Payment//Primary:
Clinical Information	Weight in kg://Weight:			Source of Payment	Foreign Government//Specify:
Clinical Information	Weight Status//ST=	Value or status is reported, not both		Clinical Information	Height Measurement Date
Clinical Information	Weight Growth percentiles//%ile	Calculated for display only		Clinical Information	Height in cm://Height:
Clinical Information	BMI:	Display Only - Cascades from Database		Clinical Information	Height Status//ST=	Value or status is reported, not both
Clinical Information	BMI://%ile	Calculated for display only		Clinical Information	Height Growth percentiles//%ile	Calculated for display only
Clinical Information	ABO Blood Group:	Display Only - Cascades from Waitlist		Clinical Information	Weight Measurement Date
Clinical Information	Primary Diagnosis:			Clinical Information	Weight in kg://Weight:
Clinical Information	Primary Diagnosis//Specify:			Clinical Information	Weight Status//ST=	Value or status is reported, not both
General Medical Factors	Diabetes:			Clinical Information	Weight Growth percentiles//%ile	Calculated for display only
General Medical Factors	Dialysis:			Clinical Information	BMI:	Display Only - Cascades from Database
General Medical Factors	Symptomatic Cerebrovascular Disease:			Clinical Information	BMI://%ile	Calculated for display only
General Medical Factors	Any previous Malignancy:			Clinical Information	ABO Blood Group:	Display Only - Cascades for Waitlist
General Medical Factors	Any previous Malignancy//Specify Type:			Clinical Information	Primary Diagnosis:
General Medical Factors	Any previous Malignancy//Specify:			Clinical Information	Primary Diagnosis//Specify:
General Medical Factors	Most Recent Serum Creatinine:			General Medical Factors	Diabetes:
General Medical Factors	Most Recent Serum Creatinine//ST=	Value or status is reported, not both		General Medical Factors	Dialysis:
Heart Medical Factors	Implantable Defibrillator:			General Medical Factors	Symptomatic Cerebrovascular Disease:
Heart Medical Factors	Exercise Oxygen Consumption:			General Medical Factors	Any previous Malignancy:
Heart Medical Factors	Exercise Oxygen Consumption//ST=	Value or status is reported, not both		General Medical Factors	Any previous Malignancy//Specify Type:
Heart Medical Factors	PA (sys) mm/Hg:			General Medical Factors	Any previous Malignancy//Specify:
Heart Medical Factors	PA (sys) mm/Hg//ST=	Value or status is reported, not both		General Medical Factors	Most Recent Serum Creatinine:
Heart Medical Factors	PA (sys) mm/Hg Inotropes/Vasodilators			General Medical Factors	Most Recent Serum Creatinine//ST=	Value or status is reported, not both
Heart Medical Factors	PA (dia) mm/Hg:			General Medical Factors	Total Serum Albumin:
Heart Medical Factors	PA (dia) mm/Hg//ST=	Value or status is reported, not both		General Medical Factors	Total Serum Albumin//ST=	Value or status is reported, not both
Heart Medical Factors	PA (dia) mm/Hg Inotropes/Vasodilators			Heart Medical Factors	Sudden Death:
Heart Medical Factors	PA (mean) mm/Hg:			Heart Medical Factors	Implantable Defibrillator:
Heart Medical Factors	PA (mean) mm/Hg//ST=	Value or status is reported, not both		Heart Medical Factors	Exercise Oxygen Consumption:
Heart Medical Factors	PA (mean) mm/Hg Inotropes/Vasodilators			Heart Medical Factors	Exercise Oxygen Consumption//ST=	Value or status is reported, not both
Heart Medical Factors	PCW (mean) mm/Hg:			Heart Medical Factors	PA (sys) mm/Hg:
Heart Medical Factors	PCW (mean) mm/Hg//ST=	Value or status is reported, not both		Heart Medical Factors	PA (sys) mm/Hg//ST=	Value or status is reported, not both
Heart Medical Factors	PCW (mean) mm/Hg Inotropes/Vasodilators			Heart Medical Factors	PA (sys) mm/Hg Inotropes/Vasodilators
Heart Medical Factors	CO L/min:			Heart Medical Factors	PA (dia) mm/Hg:
Heart Medical Factors	CO L/min//ST=	Value or status is reported, not both		Heart Medical Factors	PA (dia) mm/Hg//ST=	Value or status is reported, not both
Heart Medical Factors	CO L/min Inotropes/Vasodilators			Heart Medical Factors	PA (dia) mm/Hg Inotropes/Vasodilators
Heart Medical Factors	History of Cigarette Use:			Heart Medical Factors	PA (mean) mm/Hg:
Heart Medical Condition	Duration of Abstinence:			Heart Medical Factors	PA (mean) mm/Hg//ST=	Value or status is reported, not both
Heart Medical Condition	Prior Cardiac Surgery (non-transplant):			Heart Medical Factors	PA (mean) mm/Hg Inotropes/Vasodilators
Heart Medical Condition	If yes, check all that apply:			Heart Medical Factors	PCW (mean) mm/Hg:
Heart Medical Condition	Prior Cardiac Surgery type//Specify:			Heart Medical Factors	PCW (mean) mm/Hg//ST=	Value or status is reported, not both
				Heart Medical Factors	PCW (mean) mm/Hg Inotropes/Vasodilators
				Heart Medical Factors	CO L/min:
PUBLIC BURDEN STATEMENT:				Heart Medical Factors	CO L/min//ST=	Value or status is reported, not both
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 0.27 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].				Heart Medical Factors	CO L/min Inotropes/Vasodilators
				Heart Medical Factors	History of Cigarette Use:
				Windows User: Heart word is misspelled. UNOS: Corrected. Heart Medical Condition	Duration of Abstinence:
				Heart Medical Condition	Prior Thoracic Surgery other than prior transplant:
				Heart Medical Condition	Prior Thoracic Surgery//If yes, number of prior sternotomies:
				Heart Medical Condition	Prior Thoracic Surgery//If yes, number of prior thoracotomies:
				Heart Medical Condition	Prior Thoracic Surgery//Prior congenital cardiac surgery:
				Heart Medical Condition	Prior congenital cardiac surgery//If yes, palliative surgery:
				Heart Medical Condition	Prior congenital cardiac surgery//If yes, corrective surgery:
				Heart Medical Condition	Prior congenital cardiac surgery//If yes, single ventricular physiology:
				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 0.27 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].