VCA

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TRF - VCA - Adult/Pediatric
Fields to be completed by members
Form Section

Field Label

Recipient Information

Recipient First Name

Recipient Information

Recipient Last Name

Recipient Information

Recipient Middle Initial

Recipient Information

DOB

Recipient Information

SSN

Recipient Information
Recipient Information

Gender
HIC

Recipient Information
Recipient Information
Recipient Information
Provider Information
Provider Information
Provider Information
Provider Information
Provider Information

Transplant Date
State of Permanent Residence
Permanent zip code
Treating Reconstructive Surgeon Name
Treating Reconstructive Surgeon NPI#
Treating Transplant Physician Name
Treating Transplant Physician NPI#
Follow-up Care Provided By:

Donor Information

UNOS Donor ID #

Donor Information

Donor Type

Donor Information
Patient Status
Patient Status
Patient Status
Patient Status

OPO
Date Last Seen, Retransplanted, or Death
Patient Status
Primary Cause of Death
Primary Cause of Death - Other Specify
Has patient been hospitalized since the Last
Patient Status Date
Number of Hospitalizations
Working for income
Working for income - If Yes, indicate the
recipient's working status
Working for income - If No, Not Working Due
To
Grant funding
Institutional funding
Primary Source of Payment
Primary Source of Payment - Foreign
Government, Specify
Secondary Source of Payment
Motor Development
Psychosocial consult performed

Patient Status
Patient Status
Socio-Demographic Information
Socio-Demographic Information
Socio-Demographic Information
Socio-Demographic Information - Source of Payment
Socio-Demographic Information - Source of Payment
Socio-Demographic Information - Source of Payment
Socio-Demographic Information - Source of Payment
Socio-Demographic Information - Source of Payment
Functional Status
Functional Status
Functional Status: Pre-transplant - SF-12 score - Physical
Health
Functional Status: Pre-transplant - SF-12 score - Physical
Health
Functional Status: Pre-transplant - SF-12 score - Physical
Health
Functional Status: Pre-transplant - SF-12 score - Physical
Health
Functional Status: Pre-transplant - SF-12 score - Physical
Health
Functional Status: Pre-transplant - SF-12 score - Mental
Health
Functional Status: Pre-transplant - SF-12 score - Mental
Health
Functional Status: Pre-transplant - SF-12 score - Mental
Health
Functional Status: Pre-transplant - SF-12 score - Mental
Health
Functional Status: Pre-transplant - SF-12 score - Mental
Health
Functional Status - Upper Limb
Functional Status - Upper limb
Functional Status - Upper limb
Functional Status - Upper limb
Functional Status - Upper limb
Functional Status - Upper limb
Functional Status - Upper limb

Physical Functioning (PF) score
Role-Physical (RP) score
Bodily Pain (BP) score
General Health (GH) score
Physical Component Summary (PCS) score
Vitality (VT) score
Social Functioning (SF) score
Role-Emotional (RE) score
Mental Heath (MH) score
Mental Component Summary (MCS) score
DASH Score
Hot and cold sensation
Two-point discrimination test
Grip strength and pinch test
Is the patient able to make a fist?
Can the patient comb their hair?
Can the patient open a door?

Functional Status - Upper limb
Functional Status - Upper limb
Functional Status - Head and Neck
Functional Status - Head and Neck
Functional Status - Craniofacial
Functional Status - Craniofacial - Sensory Testing
Functional Status - Craniofacial - Sensory Testing
Functional Status - Craniofacial - Motor function
Functional Status - Craniofacial - Motor function
Functional Status - Craniofacial

Can the patient write on a piece of paper?
Can the patient hold a cup?
Smile restoration
Ability to open and close eyelids
Olfactory function restored
Two-point discrimination test
Hot and cold sensation
Oral competence
Corneal protection
Functional occlusion restored

Functional Status - Craniofacial

Decannulation (if the patient had a tracheostomy)
Feeding Tube Removed (if the patient had a
feeding tube to start with)

Functional Status - Craniofacial
Functional Status - Craniofacial - Speech Intelligibility
Tests
Functional Status - Craniofacial - Speech Intelligibility
Tests
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus

Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus

Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus

Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus

Speaking rate
Percent Intelligibility
Number of embryo transfers during this follow-up
period
{For each transfer} Number of embryo transfers//
Embryo transfer date
{For each transfer} Number of embryo transfers//
Reason if no embryo transfer date
Number of pregnancies post-transplant of uterus
during this follow-up period (which may or may
not have resulted in a live birth)
{For each pregnancy} Date of positive pregnancy
test result post-transplant
{For each pregnancy} Date of positive pregnancy
test result post-transplant//Reason if no date of
positive pregnancy test result
{For each pregnancy} Date embryonic heartbeat
first detected by ultrasound
{For each pregnancy} Date embryonic heartbeat
first detected by ultrasound// Reason if no date of
embryonic heartbeat first detected by ultrasound
{For each pregnancy} Estimated delivery date
{For each pregnancy} Estimated delivery date//
Reason if no estimated delivery date
{For each pregnancy} Pregnancy complications
{For each pregnancy} Pregnancy complications//
If yes, specify
{For each pregnancy} Did pregnancy result in a
miscarriage?
{For each pregnancy} Did pregnancy result in a
miscarriage?// If yes, date of miscarriage
{For each pregnancy} Date of admission to
Transplant Center for delivery
{For each pregnancy} Date of admission to
Transplant Center for delivery// Reason if no date
of admission to Transplant Center for delivery
{For each pregnancy} Delivery type
{For each pregnancy} Delivery type// Delivery
date
{For each pregnancy} Maternal complications at
delivery
{For each pregnancy} Maternal complications at
delivery// If yes, specify
{For each pregnancy} Blood transfusions
required following delivery
{For each pregnancy} Date of discharge from
Transplant Center post-delivery
{For each pregnancy} Date of discharge from
Transplant Center post-delivery// Reason if no
date of discharge from Transplant Center postdelivery
{For each pregnancy} Post-delivery
complications
{For each pregnancy} Post-delivery
complications// If yes, specify
{For each pregnancy} Subsequent surgeries since
delivery
{For each surgical procedure} Subsequent
surgeries since delivery// If yes, enter each
surgical procedure
{For each surgical procedure} Subsequent
surgeries since delivery// Surgical date
Readmitted to the hospital

Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Functional Status - Uterus
Clinical Information
Clinical Information
Clinical Information
Clinical Information - Noncompliance
Clinical Information - Noncompliance
Clinical Information - Noncompliance
Clinical Information - Noncompliance
Clinical Information - Noncompliance
Clinical Information
Clinical Information
Clinical Information
Clinical Information - Causes of Graft Failure
Clinical Information - Causes of Graft Failure
Clinical Information - Causes of Graft Failure
Clinical Information - Causes of Graft Failure
Clinical Information - Causes of Graft Failure
Clinical Information - Causes of Graft Failure
Clinical Information - Causes of Graft Failure
Clinical Information - Causes of Graft Failure
Clinical Information - Causes of Graft Failure
Clinical Information - Causes of Graft Failure
Clinical Information - Causes of Graft Failure
Clinical Information - Causes of Graft Failure
Clinical Information - Most Recent Lab Data
Clinical Information - Most Recent Lab Data
Clinical Information - Most Recent Lab Data
Clinical Information - Post Transplant
Clinical Information - Post Transplant
Clinical Information
Clinical Information
Clinical Information
Clinical Information
Clinical Information
Clinical Information - Complications
Clinical Information - Complications
Clinical Information - Complications
Clinical Information - Complications
Clinical Information - Complications
Clinical Information - Upper limb
Clinical Information - Upper limb
Clinical Information - Upper limb

{For each readmission} Readmitted to the
hospital// If yes, reason for readmission
{For each readmission} Readmitted to the
hospital// If yes, readmission date
Hysterectomy performed following successful
delivery or due to complication
Hysterectomy performed following successful
delivery or due to complication // Hysterectomy
date
Hysterectomy performed following successful
delivery or due to complication // If yes, then
specify reason
Hysterectomy performed following successful
delivery or due to complication // If yes and
reason is other // Other specify
Surgical, medical, or psychiatric complications
after hysterectomy
{For each complication} Surgical, medical, or
psychiatric complications after hysterectomy// If
yes, specify each complication
{For each complication} Surgical, medical, or
psychiatric complications after hysterectomy// If
yes, date
New onset diagnosed psychiatric condition(s)
New onset diagnosed psychiatric condition(s)// If
yes, specify
Visual changes noted on cervical examination
Visual changes noted on cervical examination// If
yes, specify
Height (inches)
Weight (lbs.)
BMI (Body Mass Index)
Immunosuppression
Rehabilitation
Level of Activity
Other
Other - Other Specify
Graft Status
Date of Graft Failure
{If Graft Status = Planned Removal} Date of
Removal
Acute Rejection
Acute Rejection - Banff score
Acute Rejection - Visual skin changes
Chronic Rejection
Chronic Rejection - Visual skin changes
Vascular complications
Sepsis / Infection
Trauma
Patient requested removal
Non-adherence
Other
Other - Other Specify
Serum Creatinine (mg/dL)
Hemoglobin A1c (%)
Donor Specific Antibodies (DSA)
Did patient have any acute rejection episodes
during the follow-up period
Did patient have any acute rejection episodes
during the follow-up period - Number of episodes
{For each episode} Date of acute rejection
diagnosis
{For each episode} Acute rejection was treated
{For each episode} Visual skin changes
{For each episode} Biopsy was done to confirm
acute rejection
{For each episode} Banff Score
New onset diabetes
Metabolic Complications
Infectious Complications
Other Complications
Other Complications - Other Specify
Subsequent surgeries required
{For each surgical procedure} Subsequent
surgeries required// If yes, enter each surgical
procedure
{For each surgical procedure} Subsequent
surgeries required// Surgical date

Clinical Information
Post Transplant Malignancy
Clinical Information - Post-transplant Malignancy
Donor Related
Clinical Information - Post-transplant Malignancy - Donor
Diagnosis date:
Related
Clinical Information - Post-transplant Malignancy - Donor
Tumor type
Related
Clinical Information - Post-transplant Malignancy
Recurrence of Pre-Tx Tumor
Clinical Information - Post-transplant Malignancy Date of recurrence
Recurrence of Pretransplant Malignancy
Clinical Information - Post-transplant Malignancy Type of pre-existing tumor
Recurrence of Pretransplant Malignancy
Clinical Information - Post-transplant Malignancy Type of pre-existing tumor - Other, Specify
Recurrence of Pretransplant Malignancy
Clinical Information - Post-transplant Malignancy
De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Diagnosis date
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: Skin: //squamous cell:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: Skin: //basal cell:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: Skin: //melanoma:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Kaposi's sarcoma: cutaneous:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Kaposi's sarcoma: visceral:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Brain:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: Brain: //Other specify:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Renal carcinoma - specify site(s):
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post Tumor Types: //Carcinoma of vulva, perineum or
Transplant De Novo Solid Tumor
penis, scrotum:
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Carcinoma of the uterus:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Ovarian:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Testicular:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Esophagus:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Stomach:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Small intestine:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Pancreas:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Larynx:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Tongue, throat:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Thyroid:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Bladder:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Breast:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Prostate:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Colo-rectal:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Primary hepatic tumor:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Metastatic liver tumor:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Lung:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types://Leukemia:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Sarcomas:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Other cancers:
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Other Cancers: //Site(s):
Transplant De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post
Tumor Types: //Primary unknown:
Transplant De Novo Solid Tumor
De Novo Lymphoproliferative disease and
Clinical Information - Post-transplant Malignancy
Lymphoma
Clinical Information - Post-transplant Malignancy - Post
Transplant Lymphoproliferative Disease and Lymphoma PTLD: //Diagnosis date:
Clinical Information - Post-transplant Malignancy - Post
Transplant Lymphoproliferative Disease and Lymphoma PTLD: //Pathology:

Clinical Information - Post-transplant Malignancy - Post
Transplant Lymphoproliferative Disease and Lymphoma
Treatment
Treatment
Treatment
Topical Immunosuppressive Medications

PTLD: Pathology: //Other Specify:
Antiviral
Antibiotic
Antifungal
Immunosuppression medications

Topical Immunosuppressive Medications
Topical Immunosuppressive Medications
Topical Immunosuppressive Medications
Topical Immunosuppressive Medications
Non-Topical Immunosuppressive Medications

Immunosuppression medications - Other Specify
Previous maintenance indication
Current maintenance indication
Anti-rejection indication
Immunosuppression medications

Non-Topical Immunosuppressive Medications
Non-Topical Immunosuppressive Medications
Non-Topical Immunosuppressive Medications
Non-Topical Immunosuppressive Medications

Immunosuppression medications - Other Specify
Previous maintenance indication
Current maintenance indication
Anti-rejection indication

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whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An ag
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
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§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
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
Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public rep
burden for this collection of information is estimated to average 0.27 hours per response, including the time for reviewing instructions, searching existing data sourc
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, includin
suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

tric
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Notes
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Worksheet
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Date or reason is reported, not both

Date or reason is reported, not both

Date or reason is reported, not both
Date or reason is reported, not both

Date or reason is reported, not both

Date or reason is reported, not both

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Only applicable for Uterus

Not applicable for Uterus

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Not applicable for Uterus
Not applicable for Uterus

mation in order to perform the following OPTN functions: to assess
ompliance of member organizations with OPTN Obligations. An agency
unless it displays a currently valid OMB control number. The OMB
ormation collection is required to obtain or retain a benefit per 42 CFR
ords #09-15-0055). Data collected by the private non-profit OPTN also are
meets or exceeds the requirements as prescribed by OMB Circular A-130,
Information Systems Security Program Handbook. The public reporting
the time for reviewing instructions, searching existing data sources, and
mate or any other aspect of this collection of information, including
14N136B, Rockville, Maryland, 20857 or [email protected].