51 VCA Transplant Recipient Registration_Form_clean.xlsx

TRR - VCA - Adult/Pediatric
Fields to be completed by members
Form Section	Field Label	Notes
Recipient Information	Recipient First Name	Display Only - Cascades from Removal Worksheet
Recipient Information	Recipient Last Name	Display Only - Cascades from Removal Worksheet
Recipient Information	Recipient Middle Initial	Display Only - Cascades from Removal Worksheet
Recipient Information	DOB	Display Only - Cascades from Removal Worksheet
Recipient Information	SSN	Display Only - Cascades from Removal Worksheet
Recipient Information	Gender	Display Only - Cascades from Removal Worksheet
Recipient Information	HIC
Recipient Information	Transplant Date	Display Only - Cascades from Removal Worksheet
Recipient Information	State of Permanent Residence
Recipient Information	Permanent Zip Code
Provider Information	Recipient Center	Display Only - Cascades from Removal Worksheet
Provider Information	Lead Reconstructive Surgeon Name
Provider Information	Lead Reconstructive Surgeon NPI#
Donor Information	UNOS Donor ID #	Display Only - Cascades from Removal Worksheet
Donor Information	Donor Type	Display Only - Cascades from Removal Worksheet
Donor Information	OPO	Display Only - Cascades from Removal Worksheet
Patient Status - Transplant hospitalization	Date of Admission to Transplant Center
Patient Status - Transplant hospitalization	Date of Discharge from Hospital
Patient Status	Date Last Seen, Retransplanted, or Death
Patient Status	Patient Status
Patient Status	Primary Cause of Death
Patient Status	Primary Cause of Death - Other Specify
Socio-Demographic Information: Pre-Transplant	Highest Education Level
Socio-Demographic Information: Pre-Transplant	Working for income
Socio-Demographic Information: Pre-Transplant	Working for income - If Yes, indicate the recipient's working status
Socio-Demographic Information: Pre-Transplant	Working for income - If No, Not Working Due To
Socio-Demographic Information: Pre-Transplant - Source of Payment	Grant Funding
Socio-Demographic Information: Pre-Transplant - Source of Payment	Institutional Funding
Socio-Demographic Information: Pre-Transplant - Source of Payment	Primary Source of Payment
Socio-Demographic Information: Pre-Transplant - Source of Payment	Primary Source of Payment - Foreign Government, Specify
Socio-Demographic Information: Pre-Transplant - Source of Payment	Secondary Source of Payment
Clinical Information: Pre-transplant	Height (inches)
Clinical Information: Pre-transplant	Weight (lbs.)
Clinical Information: Pre-transplant	BMI (Body Mass Index)	Display Only - Calculated
Clinical Information: Pre-transplant	Primary Diagnosis for Transplant
Clinical Information: Pre-transplant	Primary Diagnosis for Transplant - Other Specify
Clinical Information: Pre-transplant - Amount of Tissue Loss	Craniofacial
Clinical Information: Pre-transplant - Amount of Tissue Loss	Craniofacial - Partial Face - Specify anatomic structures missing
Clinical Information: Pre-transplant - Amount of Tissue Loss	Craniofacial - Other Specify
Clinical Information: Pre-transplant - Amount of Tissue Loss	Abdominal Wall (cm2)
Clinical Information: Pre-transplant - Amount of Tissue Loss	Other VCA Organ Type - Other Specify
Clinical Information: Pre-transplant - Level of Amputation	Upper Limb, Left
Clinical Information: Pre-transplant - Level of Amputation	Upper Limb, Left - Other Specify
Clinical Information: Pre-transplant - Level of Amputation	Upper Limb, Right
Clinical Information: Pre-transplant - Level of Amputation	Upper Limb, Right - Other Specify
Clinical Information: Pre-transplant - Level of Amputation	Lower Limb, Left
Clinical Information: Pre-transplant - Level of Amputation	Lower Limb, Left - Other Specify
Clinical Information: Pre-transplant - Level of Amputation	Lower Limb, Right
Clinical Information: Pre-transplant - Level of Amputation	Lower Limb, Right - Other Specify
Clinical Information: Pre-transplant	Previous Transplants (VCA or non-VCA organs)
Clinical Information: Pre-transplant	Previous skin graft(s)	Not applicable for Uterus
Clinical Information: Pre-transplant	Was patient hospitalized during the last 90 days prior to the transplant admission
Clinical Information: Pre-transplant	Medical condition at time of transplant
Clinical Information: Pre-transplant - Viral Detection	HIV Serostatus
Clinical Information: Pre-transplant - Viral Detection	CMV Status
Clinical Information: Pre-transplant - Viral Detection	HBV Core Antibody
Clinical Information: Pre-transplant - Viral Detection	HBV Surface Antigen
Clinical Information: Pre-transplant - Viral Detection	HCV Serostatus
Clinical Information: Pre-transplant - Viral Detection	EBV Serostatus
Clinical Information: Pre-transplant - Viral Detection	Did the recipient receive Hepatitis B vaccines prior to transplant?
Clinical Information: Pre-transplant	Any tolerance induction technique used
Clinical Information: Pre-transplant	Pre-transplant blood transfusions
Clinical Information: Pre-transplant	Number of pre-transplant pregnancies (which may or may not have resulted in a live birth)
Clinical Information: Pre-transplant	Malignancies prior to transplant
Clinical Information: Pre-transplant	Malignancies prior to transplant - If Yes, Specify Type (select all that apply)
Clinical Information: Pre-transplant - Pre-Transplant Labs	Serum Creatinine (mg/dL)
Clinical Information: Pre-transplant - Pre-Transplant Labs	Hemoglobin A1c (%)
Clinical Information: Pre-transplant - Pre-Transplant Labs	Calculated PRA (CPRA) at transplant (%)
Clinical Information: Pre-transplant - Pre-Transplant Labs	Donor Crossmatch Result
Functional Status: Pre-transplant	Motor Development
Functional Status: Pre-transplant - SF-12 score - Physical Health	Physical Functioning (PF) score
Functional Status: Pre-transplant - SF-12 score - Physical Health	Role-Physical (RP) score
Functional Status: Pre-transplant - SF-12 score - Physical Health	Bodily Pain (BP) score
Functional Status: Pre-transplant - SF-12 score - Physical Health	General Health (GH) score
Functional Status: Pre-transplant - SF-12 score - Physical Health	Physical Component Summary (PCS) score
Functional Status: Pre-transplant - SF-12 score - Mental Health	Vitality (VT) score
Functional Status: Pre-transplant - SF-12 score - Mental Health	Social Functioning (SF) score
Functional Status: Pre-transplant - SF-12 score - Mental Health	Role-Emotional (RE) score
Functional Status: Pre-transplant - SF-12 score - Mental Health	Mental Heath (MH) score
Functional Status: Pre-transplant - SF-12 score - Mental Health	Mental Component Summary (MCS) score
Functional Status: Pre-transplant - Upper Limb - Pre-Transplant	DASH Score
Clinical Information: Transplant Procedure	Multiple Graft Recipient
Clinical Information: Transplant Procedure	Were extra allograft vessels/nerve/tissue from outside the donated graft used in the transplant procedure
Clinical Information: Transplant Procedure	Surgical Procedure	Display Only - Cascades from Removal Worksheet
Clinical Information: Transplant Procedure - Preservation Information	Warm Ischemia Time (include anastomotic time)
Clinical Information: Transplant Procedure - Preservation Information	Cold Ischemia Time
Clinical Information: Post Transplant	Graft Status
Clinical Information: Post Transplant	Date of Graft Failure
Clinical Information: Post Transplant	{If Graft Status = Planned Removal} Date of Removal	Only applicable for Uterus
Clinical Information: Post Transplant - Causes of Graft Failure	Acute Rejection
Clinical Information: Post Transplant - Causes of Graft Failure	Acute Rejection - Banff score
Clinical Information: Post Transplant - Causes of Graft Failure	Acute Rejection - Visual skin changes	Not applicable for Uterus
Clinical Information: Post Transplant - Causes of Graft Failure	Chronic Rejection
Clinical Information: Post Transplant - Causes of Graft Failure	Chronic Rejection - Visual skin changes
Clinical Information: Post Transplant - Causes of Graft Failure	Vascular complications
Clinical Information: Post Transplant - Causes of Graft Failure	Sepsis / Infection
Clinical Information: Post Transplant - Causes of Graft Failure	Trauma
Clinical Information: Post Transplant - Causes of Graft Failure	Patient requested removal
Clinical Information: Post Transplant - Causes of Graft Failure	Non-adherence
Clinical Information: Post Transplant - Causes of Graft Failure	Other
Clinical Information: Post Transplant - Causes of Graft Failure	Other - Other Specify
Clinical Information: Post Transplant - Discharge Lab Data	Serum Creatinine (mg/dL)
Clinical Information: Post Transplant - Discharge Lab Data	Hemoglobin A1c (%)
Clinical Information: Post Transplant - Major Transplant Complication	Arterial Thrombosis
Clinical Information: Post Transplant - Major Transplant Complication	Venous Thrombosis
Clinical Information: Post Transplant - Major Transplant Complication	More than 5 pRBC (packed red blood cells) units
Clinical Information: Post Transplant - Major Transplant Complication	Cardiac arrest
Clinical Information: Post Transplant - Major Transplant Complication	DIC (Disseminated intravascular coagulation)
Clinical Information: Post Transplant - Major Transplant Complication	Graft/reperfusion syndrome
Clinical Information: Post Transplant - Major Transplant Complication	Other Major Transplant Complications
Clinical Information: Post Transplant - Major Transplant Complication	Other Major Transplant Complications - Other Specify
Clinical Information: Post Transplant	Did patient have any acute rejection episodes between transplant and discharge
Clinical Information: Post Transplant	Did patient have any acute rejection episodes between transplant and discharge - Number of episodes
Clinical Information: Post Transplant	{For each episode} Date of acute rejection diagnosis
Clinical Information: Post Transplant	{For each episode} Acute rejection was treated
Clinical Information: Post Transplant	{For each episode} Visual skin changes
Clinical Information: Post Transplant	{For each episode} Biopsy was done to confirm acute rejection
Clinical Information: Post Transplant	{For each episode} Banff Score
Clinical Information: Post-transplant - Upper Limb	Subsequent surgeries required
Clinical Information: Post-transplant - Upper Limb	{For each surgical procedure} Subsequent surgeries required// If yes, enter each surgical procedure
Clinical Information: Post-transplant - Upper Limb	{For each surgical procedure} Subsequent surgeries required// Surgical date
Functional Status: Post-transplant - Head and Neck	Smile restoration
Functional Status: Post-transplant - Head and Neck	Ability to open and close eyelids
Functional Status: Post-transplant - Uterus	Prior reconstructive gynecological procedures
Functional Status: Post-transplant - Uterus	Prior reconstructive gynecological procedures// If yes, specify procedure(s)
Functional Status: Post-transplant - Uterus	Prior pregnancies
Functional Status: Post-transplant - Uterus	Diagnosed psychiatric condition(s) pre-transplant
Functional Status: Post-transplant - Uterus	Diagnosed psychiatric condition(s) pre-transplant// If yes, specify condition(s)
Functional Status: Post-transplant - Uterus	Subsequent surgeries required during admission
Functional Status: Post-transplant - Uterus	{For each surgical procedure}Subsequent surgeries required during admission// If yes, enter each surgical procedure
Functional Status: Post-transplant - Uterus	{For each surgical procedure}Subsequent surgeries required during admission// Surgical date
Functional Status: Post-transplant - Uterus	Visual changes noted on cervical examination
Functional Status: Post-transplant - Uterus	Visual changes noted on cervical examination// If yes, specify
Treatment	Antiviral Prophylaxis
Treatment	Antibacterial Prophylaxis
Treatment	Antifungal Prophylaxis
Treatment	Peri-operative anticoagulation
Topical Immunosuppressive Medications	Immunosuppression medications	Not applicable for Uterus
Topical Immunosuppressive Medications	Immunosuppression medications - Other Specify	Not applicable for Uterus
Topical Immunosuppressive Medications	Maintenance indication	Not applicable for Uterus
Topical Immunosuppressive Medications	Anti-rejection indication	Not applicable for Uterus
Non-Topical Immunosuppressive Medications	Immunosuppression medications
Non-Topical Immunosuppressive Medications	Immunosuppression medications - Other Specify
Non-Topical Immunosuppressive Medications	Induction indication
Non-Topical Immunosuppressive Medications	Number of days of induction
Non-Topical Immunosuppressive Medications	Maintenance indication
Non-Topical Immunosuppressive Medications	Anti-rejection 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].