9 Heart Transplant Recipient Follow Up 1_5 Year _Form_Clea

	TRF(1-5 Years) - Heart - Adult					TRF(1-5 year) - Heart - 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 Type	Display Only - Cascades from TCR		Recipient Information	Previous Px Stat Date	Display Only - Cascades from prior TRF
	Provider Information	Recipient Center	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	Recipient Center	Display Only - Cascades from TCR
	Provider Information	Follow-up Center Type	Display Only - Cascades from Database		Provider Information	Follow-up Center Code	Display Only - Cascades from Database
	Provider Information	Physician Name			Provider Information	Follow-up Center Type	Display Only - Cascades from Database
	Provider Information	NPI#			Provider Information	Physician Name
	Provider Information	Follow-up Care Provided By			Provider Information	NPI#
	Provider Information	Follow-up Care Provided By//Specify			Provider Information	Follow-up Care Provided By
	Donor Information	UNOS Donor ID #	Display Only - Cascades from Database		Provider Information	Follow-up Care Provided By//Specify
	Donor Information	Donor Type	Display Only - Cascades from Database		Donor Information	UNOS Donor ID #	Display Only - Cascades from Database
	Donor Information	OPO	Display Only - Cascades from feedback		Donor Information	Donor Type	Display Only - Cascades from Database
	Patient Status	Date: Last Seen, Retransplanted or Death			Donor Information	OPO	Display Only - Cascades from feedback
	Patient Status	Patient Status			Patient Status	Date: Last Seen, Retransplanted or Death
	Patient Status	Primary Cause of Death			Patient Status	Patient Status
	Patient Status	Primary Cause of Death//Specify			Patient Status	Primary Cause of Death
	Patient Status	Contributory Cause of Death	Not required		Patient Status	Primary Cause of Death//Specify
	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	Contributory Cause of Death	Not required
	Patient Status	Has the patient been hospitalized since the last patient status date			Patient Status	Contributory Cause of Death//Specify	Not required
	Patient Status	Hospitalized for Rejection			Patient Status	Has the patient been hospitalized since the last patient status date
	Patient Status	Hospitalized for Infection			Patient Status	Hospitalized for Rejection
	Patient Status	Functional Status			Patient Status	Hospitalized for Infection
	Patient Status	Working for income			Patient Status	Functional Status
	Patient Status	Primary Insurance at Follow-up			Patient Status at Time of Follow-up	Cognitive Development
	Patient Status	Primary Source of Payment, Specify			Patient Status at Time of Follow-up	Motor Development
	Clinical Information	Heart Graft Status			Patient Status	Working for income
	Clinical Information	Heart Date of Graft Failure			Patient Status	Academic Progress
	Clinical Information	Heart Primary Cause of Graft Failure			Patient Status	Academic Activity Level
	Clinical Information	Heart Primary Cause of Graft Failure//Other, Specify			Patient Status	Primary Insurance at Follow-up
	Clinical Information	HIV Serology			Patient Status	Primary Source of Payment, Specify
	Clinical Information	HIV NAT			Clinical Information	Height Measurement Date
	Clinical Information	HbsAg			Clinical Information	Height
	Clinical Information	HBV DNA			Clinical Information	Height//Status	Value or status is reported, not both
	Clinical Information	HBV Core Antibody			Clinical Information	Height Percentile	Calculated for display only
	Clinical Information	HCV Serology			Clinical Information	Weight Measurement Date
	Clinical Information	HCV NAT			Clinical Information	Weight
	Clinical Information	Ejection Fraction			Clinical Information	Weight//Status	Value or status is reported, not both
	Clinical Information	Heart: Ejection Fraction//Status	Value or status is reported, not both		Clinical Information	Weight Percentile	Calculated for display only
	Clinical Information	Pacemaker			Clinical Information	BMI	Display Only - Cascades from Database
	Clinical Information	Coronary Artery Disease			Clinical Information	BMI Percentile	Calculated for display only
	Clinical Information	New diabetes onset between last follow-up to the current follow-up			Clinical Information	Heart Graft Status
	Clinical Information	Diabetes: If Yes, Insulin Dependent			Clinical Information	Heart Date of Graft Failure
	Clinical Information	Most Recent Serum Creatinine			Clinical Information	Heart Primary Cause of Graft Failure
	Clinical Information	Most Recent Serum Creatinine//Status	Value or status is reported, not both		Clinical Information	Heart Primary Cause of Graft Failure//Other, Specify
	Clinical Information	Chronic Dialysis			Clinical Information	Most Recent Anti-A Titer
	Clinical Information	Renal Tx since Thoracic Tx			Clinical Information	Most Recent Anti-A Titer//Sample Date
	Clinical Information	Did patient have any acute rejection episodes during the follow-up period			Clinical Information	Most Recent Anti-B Titer
	Clinical Information	Post Transplant Malignancy			Clinical Information	Most Recent Anti-B Titer//Sample Date
	Clinical Information	Donor Related			Clinical Information	HIV Serology
	Clinical Information	Recurrence of Pre-Tx Tumor			Clinical Information	HIV NAT
	Clinical Information	De Novo Solid Tumor			Clinical Information	HbsAg
	Clinical Information	De Novo Lymphoproliferative disease and Lymphoma			Clinical Information	HBV DNA
	Immunosuppressive Information	Were any medications given during the follow-up period for maintenance			Clinical Information	HBV Core Antibody
	Immunosuppressive Information	Previous Validated Maintenance Follow-up Medications	Display Only - Cascades from Database		Clinical Information	HCV Serology
	Immunosuppression Other	Immunosuppression medication			Clinical Information	HCV NAT
	Immunosuppression Other	Immunosuppression medication indication			Clinical Information	Ejection Fraction
					Clinical Information	Heart: Ejection Fraction//Status	Value or status is reported, not both
					Clinical Information	Shortening Fraction
	PUBLIC BURDEN STATEMENT:				Clinical Information	Shortening Fraction://Status	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].				Clinical Information	Pacemaker
					Clinical Information	Coronary Artery Disease Since Last Follow Up
					Clinical Information	Did patient have any acute rejection episodes during the follow-up period
					Clinical Information	New diabetes onset between last follow-up to the current follow-up
					Clinical Information	Diabetes: If Yes, Insulin Dependent
					Clinical Information	Most Recent Serum Creatinine
					Clinical Information	Most Recent Serum Creatinine//Status	Value or status is reported, not both
					Clinical Information	Chronic Dialysis
					Clinical Information	Renal Tx since Thoracic Tx
					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	Diabetes onset during the follow-up period
					Clinical Information	If yes, insulin dependent
					Immunosuppressive Information	Were any medications given during the follow-up period for maintenance
					Immunosuppressive Information	Previous Validated Maintenance Follow-up Medications	Display Only - Cascades from Database
					Immunosuppression Other	Immunosuppression medication
					Immunosuppression Other	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 0.27 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].