Intestine Transplant Recipient Follow Up Post 5 Year_Form_redline.xlsx

Data System for Organ Procurement and Transplantation Network

Intestine Transplant Recipient Follow Up Post 5 Year_Form_redline.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
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 Date of Measurement
Clinical Information Graft Status
Clinical Information Height Measurement Date
Clinical Information Date of Failure
Clinical Information Height
Clinical Information Primary Cause of Failure
Clinical Information Height//Status Value or status is reported, not both
Clinical Information Primary Cause of Failure//Other, Specify
Clinical Information Height Percentile Calculated for display only
Clinical Information Most Recent Serum Creatinine
Clinical Information Weight Measurement Date
Clinical Information Most Recent Serum Creatinine://Status Value or status is reported, not both
Clinical Information Weight
Clinical Information Post Transplant Malignancy
Clinical Information Weight//Status Value or status is reported, not both
Clinical Information Donor Related
Clinical Information Weight Percentile Calculated for display only
Clinical Information Recurrence of Pre-Tx Tumor
Clinical Information BMI Display Only - Cascades from Database
Clinical Information De Novo Solid Tumor
Clinical Information BMI Percentile Calculated for display only
Clinical Information De Novo Lymphoproliferative disease and Lymphoma
Clinical Information Graft Status




Clinical Information Date of Failure



Clinical Information Primary Cause of Failure




Clinical Information Primary Cause of Failure//Other, Specify
PUBLIC BURDEN STATEMENT:

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

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].





















































File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy