33 Liver Transplant Recipient Follow Up Post 5 Year_Form_cl

TRF (Post 5-Year) - Intestine - Adult					TRF (Post 5-Year) - Intestine - 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	Display Only - Cascades from TCR		Provider Information	Recipient Center	Display Only - Cascades from TCR
Provider Information	Recipient Center Type	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	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
Provider Information	Physician Name			Donor Information	UNOS Donor ID #	Display Only - Cascades from Database
Provider Information	NPI#			Donor Information	Donor Type	Display Only - Cascades from Database
Provider Information	Follow-up Care Provided By			Donor Information	OPO	Display Only - Cascades from feedback
Provider Information	Follow-up Care Provided By//Specify			Patient Status	Date: Last Seen, Retransplanted or Death
Donor Information	UNOS Donor ID #	Display Only - Cascades from Database		4-Patient Status	Patient Status
Donor Information	Donor Type	Display Only - Cascades from Database		4-Patient Status	Primary Cause of Death
Donor Information	OPO	Display Only - Cascades from feedback		4-Patient Status	Primary Cause of Death//Specify
Patient Status	Date: Last Seen, Retransplanted or Death			4-Patient Status	Functional Status
4-Patient Status	Patient Status			Patient Status at Time of Follow-up	Cognitive Development
4-Patient Status	Primary Cause of Death			Patient Status at Time of Follow-up	Motor Development
4-Patient Status	Primary Cause of Death//Specify			Clinical Information	Height Measurement Date
Clinical Information	Graft Status			Clinical Information	Height
Clinical Information	Date of Failure			Clinical Information	Height//Status	Value or status is reported, not both
Clinical Information	Primary Cause of Failure			Clinical Information	Height Percentile	Calculated for display only
Clinical Information	Primary Cause of Failure//Other, Specify			Clinical Information	Weight Measurement Date
Clinical Information	Most Recent Serum Creatinine			Clinical Information	Weight
Clinical Information	Most Recent Serum Creatinine://Status	Value or status is reported, not both		Clinical Information	Weight//Status	Value or status is reported, not both
Clinical Information	Post Transplant Malignancy			Clinical Information	Weight Percentile	Calculated for display only
Clinical Information	Donor Related			Clinical Information	BMI	Display Only - Cascades from Database
Clinical Information	Recurrence of Pre-Tx Tumor			Clinical Information	BMI Percentile	Calculated for display only
Clinical Information	De Novo Solid Tumor			Clinical Information	Graft Status
Clinical Information	De Novo Lymphoproliferative disease and Lymphoma			Clinical Information	Date of Failure
				Clinical Information	Primary Cause of Failure
				Clinical Information	Primary Cause of Failure//Other, Specify
				Clinical Information	Most Recent Serum Creatinine
PUBLIC BURDEN STATEMENT:				Clinical Information	If Functioning, Most Recent Serum Creatinine://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	Diabetes onset during the follow-up period
				Clinical Information	Insulin dependent
				Clinical Information	Coronary Artery Disease Since Last Follow-up
				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
				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].