24 Liver Transplant Candidate Registration_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Liver Transplant Candidate Registration_Form_clean.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
TCR - Liver - Adult
TCR - Liver - 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://Ventilator

Patient Status Life Support://Ventilator
Patient Status Life Support://Artifical Liver

Patient Status Life Support://Artifical Liver
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 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 Academic Progress:
Patient Status Previous Transplant//Graft Fail Date Display Only - Cascades from Database
Patient Status Academic Activity Level:
Patient Status Previous Pancreas Islet Infusion:

Patient Status Previous Transplant//Organ Display Only - Cascades from Database
Source of Payment Source of Payment//Primary:

Patient Status Previous Transplant//Date Display Only - Cascades from Database
Source of Payment Foreign Government//Specify:

Patient Status Previous Transplant//Graft Fail Date Display Only - Cascades from Database
Clinical Information Height in cm://Height:

Source of Payment Source of Payment//Primary:
Clinical Information Height Status//ST= Value or status is reported, not both
Source of Payment Foreign Government//Specify:
Clinical Information Height Growth percentiles//%ile Calculated for display only
Clinical Information Height Measurement Date
Clinical Information Weight in kg://Weight:
Clinical Information Height in cm://Height:
Clinical Information Weight Status//ST= Value or status is reported, not both
Clinical Information Height Status//ST= Value or status is reported, not both
Clinical Information Weight Growth percentiles//%ile Calculated for display only
Clinical Information Height Growth percentiles//%ile Calculated for display only
Clinical Information BMI: Display Only - Cascades from Database
Clinical Information Weight Measurement Date
Clinical Information BMI://%ile Calculated for display only
Clinical Information Weight in kg://Weight:
Clinical Information ABO Blood Group: Display Only - Cascades from Waitlist
Clinical Information Weight Status//ST= Value or status is reported, not both
Clinical Information Primary Diagnosis:

Clinical Information Weight Growth percentiles//%ile Calculated for display only
Clinical Information Primary Diagnosis//Specify:

Clinical Information BMI: Display Only - Cascades from Database
Clinical Information Secondary Diagnosis: Not required
Clinical Information BMI://%ile Calculated for display only
Clinical Information Secondary Diagnosis//Specify:

Clinical Information ABO Blood Group: Display Only - Cascades from Waitlist
General Medical Factors Diabetes:

Clinical Information Primary Diagnosis:
General Medical Factors Any previous Malignancy:

Clinical Information Primary Diagnosis//Specify:
General Medical Factors Any previous Malignancy//Specify Type:

Clinical Information Secondary Diagnosis: Not required
General Medical Factors Cholangiocarcinoma//Neoadjuvant Therapy

Clinical Information Secondary Diagnosis//Specify:
General Medical Factors Any previous Malignancy//Specify:

General Medical Factors Diabetes:
Clinical Information Has the candidate ever had a diagnosis of HCC?

General Medical Factors Any previous Malignancy:
Liver Medical Factors Previous Upper Abdominal Surgery:

General Medical Factors Any previous Malignancy//Specify Type:
Liver Medical Factors Spontaneous Bacterial Peritonitis:

General Medical Factors Cholangiocarcinoma//Neoadjuvant Therapy
Liver Medical Factors History of Portal Vein Thrombosis:

General Medical Factors Any previous Malignancy//Specify:
Liver Medical Factors History of TIPSS:

General Medical Factors Has the candidate ever had a diagnosis of HCC?




Liver Medical Factors Previous Upper Abdominal Surgery:



Liver Medical Factors Spontaneous Bacterial Peritonitis:




Liver Medical Factors History of Portal Vein Thrombosis:
PUBLIC BURDEN STATEMENT:

Liver Medical Factors History of TIPSS:
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].









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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