9 Heart Transplant Recipient Follow Up 1_5 Year _Form_Clea

Data System for Organ Procurement and Transplantation Network

Heart Transplant Recipient Follow Up 1_5 Year _Form_clean.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf

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].


































































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