10 Heart Transplant Recipient Follow Up Post 5 Year_Form_Cl
Data System for Organ Procurement and Transplantation Network
Heart Transplant Recipient Follow Up Post 5 Year_Form_clean.xlsx
OMB: 0915-0157
Document [xlsx]
Download: xlsx | pdf
| TRF (Post 5-Year) - Heart - Adult | TRF (Post 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 |
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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 | Provider Information | Recipient Center Type | Display Only - Cascades from TCR | |||||||||||||||||
| Provider Information | Recipient Center | Display Only - Cascades from TCR | Provider Information | Recipient Center | Display Only - Cascades from TCR | |||||||||||||||||
| Provider Information | Follow-up Center Code | Display Only - Cascades from Database | Provider Information | Follow-up Center Code | Display Only - Cascades from Database | |||||||||||||||||
| Provider Information | Follow-up Center Type | Display Only - Cascades from Database | Provider Information | Follow-up Center Type | Display Only - Cascades from Database | |||||||||||||||||
| Donor Information | UNOS Donor ID # | Display Only - Cascades from Database | Donor Information | UNOS Donor ID # | Display Only - Cascades from Database | |||||||||||||||||
| Donor Information | Donor Type | Display Only - Cascades from Database | Donor Information | Donor Type | Display Only - Cascades from Database | |||||||||||||||||
| Donor Information | OPO | Display Only - Cascades from feedback | Donor Information | OPO | Display Only - Cascades from feedback | |||||||||||||||||
| Patient Status | Date: Last Seen, Retransplanted or Death | Patient Status | Date: Last Seen, Retransplanted or Death | |||||||||||||||||||
| Patient Status | Patient Status | Patient Status | Patient Status | |||||||||||||||||||
| Patient Status | Primary Cause of Death | Patient Status | Primary Cause of Death | |||||||||||||||||||
| Patient Status | Primary Cause of Death//Specify | Patient Status | Primary Cause of Death//Specify | |||||||||||||||||||
| Clinical Information | Heart Graft Status | Patient Status | Functional Status | |||||||||||||||||||
| Clinical Information | Heart Date of Graft Failure | Patient Status at Time of Follow-up | Cognitive Development | |||||||||||||||||||
| Clinical Information | Heart Primary Cause of Graft Failure | Patient Status at Time of Follow-up | Motor Development | |||||||||||||||||||
| Clinical Information | Heart Primary Cause of Graft Failure//Other, Specify | Clinical Information | Height Measurement Date | |||||||||||||||||||
| Clinical Information | Chronic Dialysis | Clinical Information | Height | |||||||||||||||||||
| Clinical Information | Renal Tx since Thoracic Tx | Clinical Information | Height//Status | Value or status is reported, not both | ||||||||||||||||||
| Clinical Information | Most Recent Serum Creatinine | Clinical Information | Height Percentile | Calculated for display only | ||||||||||||||||||
| Clinical Information | Most Recent Serum Creatinine//Status | Value or status is reported, not both | Clinical Information | Weight Measurement Date | ||||||||||||||||||
| Clinical Information | Post Transplant Malignancy | Clinical Information | Weight | |||||||||||||||||||
| Clinical Information | Donor Related | Clinical Information | Weight//Status | Value or status is reported, not both | ||||||||||||||||||
| Clinical Information | Recurrence of Pre-Tx Tumor | Clinical Information | Weight Percentile | Calculated for display only | ||||||||||||||||||
| Clinical Information | De Novo Solid Tumor | Clinical Information | BMI | Display Only - Cascades from Database | ||||||||||||||||||
| Clinical Information | De Novo Lymphoproliferative disease and Lymphoma | Clinical Information | BMI | Calculated for display only | ||||||||||||||||||
| Clinical Information | Other, Specify | Clinical Information | Heart Graft Status | |||||||||||||||||||
| Clinical Information | Heart Date of Graft Failure | |||||||||||||||||||||
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Clinical Information | Heart Primary Cause of Graft Failure | ||||||||||||||||||||
| Clinical Information | Heart Primary Cause of Graft Failure//Other, Specify | |||||||||||||||||||||
| PUBLIC BURDEN STATEMENT: | Clinical Information | Coronary Artery Disease Since Last Follow-up | ||||||||||||||||||||
| 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 | Chronic Dialysis | ||||||||||||||||||||
| Clinical Information | Renal Tx since Thoracic Tx | |||||||||||||||||||||
| Clinical Information | Most Recent Serum Creatinine | |||||||||||||||||||||
| Clinical Information | Most Recent Serum Creatinine//Status | |||||||||||||||||||||
| Clinical Information | New diabetes onset between last follow-up to the current follow-up | |||||||||||||||||||||
| Clinical Information | Diabetes: If Yes, Insulin Dependent | |||||||||||||||||||||
| 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 | |||||||||||||||||||||
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| 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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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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