Heart Transplant Recipient Follow Up Post 5 Year_Form_redline.xlsx

Data System for Organ Procurement and Transplantation Network

Heart Transplant Recipient Follow Up Post 5 Year_Form_redline.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 Misspelled. UNOS: This is intentional due to the page real estate for displaying one or many fields in a group. 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 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 Date of Measurement















Clinical Information Chronic Dialysis

Clinical Information Height Measurement Date
















Clinical Information Renal Tx since Thoracic Tx

Clinical Information Height















Clinical Information Most Recent Serum Creatinine
Clinical Information Height//Status Value or status is reported, not both















Clinical Information Most Recent Serum Creatinine//Status Value or status is reported, not both
Clinical Information Height Percentile Calculated for display only















Clinical Information Post Transplant Malignancy
Clinical Information Weight Measurement Date
















Clinical Information Donor Related
Clinical Information Weight















Clinical Information Recurrence of Pre-Tx Tumor
Clinical Information Weight//Status Value or status is reported, not both















Clinical Information De Novo Solid Tumor
Clinical Information Weight Percentile Calculated for display only















Clinical Information De Novo Lymphoproliferative disease and Lymphoma
Clinical Information BMI Display Only - Cascades from Database















Clinical Information Other, Specify
Clinical Information BMI Calculated for display only


















Clinical Information Heart Graft Status

















Clinical Information Heart Date of Graft Failure


















Clinical Information Heart Primary Cause of Graft Failure















PUBLIC BURDEN STATEMENT:

Clinical Information Heart Primary Cause of Graft Failure//Other, Specify















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 Coronary Artery Disease Since Last Follow-up

















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


















































































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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