TRR - Lung - Adult | TRR - Lung - 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 | Display Only - Cascades from TCR | Recipient Information | Organ | Display Only - Cascades from TCR | |
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 | Not required | Recipient Information | Recipient Middle Initial | Not required | |
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 | DOB | Display Only - Cascades from TCR | Recipient Information | DOB | Display Only - Cascades from TCR | |
Recipient Information | Birth Sex | Display Only - Cascades from TCR | Recipient Information | Birth Sex | Display Only - Cascades from TCR | |
Recipient Information | Transplant Date | Display Only - Cascades from Database | Recipient Information | Transplant Date | Display Only - Cascades from Database | |
Recipient Information | Transplant Time | Display Only - Cascades from Database | Recipient Information | Transplant Time | Display Only - Cascades from Database | |
Recipient Information | Transplant Time Zone | Display Only - Cascades from Database | Recipient Information | Transplant Time Zone | Display Only - Cascades from Database | |
Recipient Information | State of Permanent Residence | Recipient Information | State of Permanent Residence | |||
Recipient Information | Permanent Zip | Recipient Information | Permanent Zip | |||
Provider Information | Recipient Center Code | Display Only - Cascades from TCR | Provider Information | Recipient Center Code | 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 | Physician Name | Provider Information | Physician Name | |||
Provider Information | Physician NPI# | Provider Information | Physician NPI# | |||
Provider Information | Surgeon Name | Provider Information | Surgeon Name | |||
Provider Information | Surgeon NPI# | Provider Information | Surgeon NPI# | |||
Donor Information | UNOS Donor ID # | Display Only - Cascades from TCR | Donor Information | UNOS Donor ID # | Display Only - Cascades from TCR | |
Donor Information | Donor Type | Display Only - Cascades from feedback | Donor Information | Donor Type | Display Only - Cascades from feedback | |
Donor Information | OPO | Display Only - Cascades from feedback | Donor Information | OPO | Display Only - Cascades from feedback | |
Patient Status | Primary Diagnosis | Patient Status | Primary Diagnosis | |||
Patient Status | Primary Diagnosis//Specify | Patient Status | Primary Diagnosis//Specify | |||
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 | Cause of Death//Specify | Patient Status | Cause of Death//Specify | |||
Patient Status | Contributory Cause of Death | Not required | Patient Status | Contributory Cause of Death | Not required | |
Patient Status | Contributory Cause of Death//Specify | Not required | Patient Status | Contributory Cause of Death//Specify | Not required | |
Patient Status | Contributory Cause of Death | Not required | Patient Status | Contributory Cause of Death | Not required | |
Patient Status | Contributory Cause of Death//Specify | Not required | Patient Status | Contributory Cause of Death//Specify | Not required | |
Patient Status | Date of Admission to Tx Center | Patient Status | Date of Admission to Tx Center | |||
Patient Status | Date of Discharge from Tx Center | Patient Status | Date of Discharge from Tx Center | |||
Pretransplant | Medical Condition at time of transplant | Pretransplant | Medical Condition at time of transplant | |||
Pretransplant | Patient on Life Support | Pretransplant | Patient on Life Support | |||
Pretransplant | Extra Corporeal Membrane Oxygenation | Pretransplant | Extra Corporeal Membrane Oxygenation | |||
Pretransplant | Intra Aortic Balloon Pump | Pretransplant | Prostaglandins | |||
Pretransplant | Other Mechanism | Pretransplant | Intravenous Inotropes | |||
Pretransplant | Other Mechanism, Specify | Pretransplant | Ventilator | |||
Pretransplant | Prostacyclin Infusion | Pretransplant | Inhaled NO | |||
Pretransplant | Prostacyclin Inhalation | Pretransplant | Other Mechanism | |||
Pretransplant | Functional Status | Pretransplant | Other Mechanism, Specify | |||
Pretransplant | Working for income | Pretransplant | Prostacyclin Infusion | |||
Pretransplant | Primary Source of Payment | Pretransplant | Prostacyclin Inhalation | |||
Pretransplant | Primary Source of Payment, Specify | Pretransplant | Life Support: VAD Brand1 | |||
Pretransplant | Height | Pretransplant | Life Support: VAD Brand1//Specify | |||
Pretransplant | Height in Centimeters//Status | Value or status is reported, not both | Pretransplant | Life Support: VAD Brand2 | ||
Pretransplant | Height Percentile//Growth Percentiles//%ile | Calculated for display only | Pretransplant | Life Support: VAD Brand2//Specify | ||
Pretransplant | Weight | Pretransplant | Functional Status | |||
Pretransplant | Weight in Kilograms//Status | Value or status is reported, not both | Pretransplant | Academic Progress | ||
Pretransplant | Weight Percentile//Growth Percentiles//%ile | Calculated for display only | Pretransplant | Academic Activity Level | ||
Pretransplant | BMI | Display Only - Cascades from Database | Pretransplant | Primary Source of Payment | ||
Pretransplant | BMI://%ile | Calculated for display only | Pretransplant | Primary Source of Payment, Specify | ||
Pretransplant | Previous Transplant Organ | Display Only - Cascades from Database | Pretransplant | Cognitive Development | ||
Pretransplant | Previous Transplant Date | Display Only - Cascades from Database | Pretransplant | Motor Development | ||
Pretransplant | Previous Transplant Graft Fail Date | Display Only - Cascades from Database | Pretransplant | Height Measurement Date | ||
Pretransplant | HIV Serostatus | Pretransplant | Height | |||
Pretransplant | NAT HIV | Pretransplant | Height in Centimeters//Status | Value or status is reported, not both | ||
Pretransplant | CMV Status | Pretransplant | Height Percentile//Growth Percentiles//%ile | Calculated for display only | ||
Pretransplant | HBV Core Antibody | Pretransplant | Weight Measurement Date | |||
Pretransplant | HBV Surface Antibody Total | Pretransplant | Weight | |||
Pretransplant | HBV Surface Antigen | Pretransplant | Weight in Kilograms//Status | Value or status is reported, not both | ||
Pretransplant | NAT HBV | Pretransplant | Weight Percentile//Growth Percentiles//%ile | Calculated for display only | ||
Pretransplant | HCV Serostatus | Pretransplant | BMI | Display Only - Cascades from Database | ||
Pretransplant | NAT HCV | Pretransplant | BMI://%ile | Calculated for display only | ||
Pretransplant | EBV Serostatus | Pretransplant | Previous Transplant Organ | Display Only - Cascades from Database | ||
Pretransplant | Did the recipient receive Hepatitis B vaccines prior to transplant? | Pretransplant | Previous Transplant Date | Display Only - Cascades from Database | ||
Pretransplant | PA (sys)mm/Hg | Pretransplant | Previous Transplant Graft Fail Date | Display Only - Cascades from Database | ||
Pretransplant | PA (sys)mm/Hg//Status | Value or status is reported, not both | Pretransplant | HIV Serostatus | ||
Pretransplant | PA(sys)mm/Hg Inotropes/VASODilators | Pretransplant | NAT HIV | |||
Pretransplant | PA(dia) mm/Hg | Pretransplant | CMV Status | |||
Pretransplant | PA(dia) mm/HG//Status | Value or status is reported, not both | Pretransplant | HBV Core Antibody | ||
Pretransplant | PA (dia) mm/Hg Inotropes/Vasodilators | Pretransplant | HBV Surface Antibody Total | |||
Pretransplant | PA(mean) mm/Hg | Pretransplant | HBV Surface Antigen | |||
Pretransplant | PA(mean) mm/Hg//Status | Value or status is reported, not both | Pretransplant | NAT HBV | ||
Pretransplant | PA (mean) mm/Hg Inotropes/Vasodilators | Pretransplant | HCV Serostatus | |||
Pretransplant | PCW(mean) mm/Hg | Pretransplant | NAT HCV | |||
Pretransplant | PCW(mean) mm/Hg//Status | Value or status is reported, not both | Pretransplant | EBV Serostatus | ||
Pretransplant | PCW (mean) mm/Hg Inotropes/Vasodilators | Pretransplant | Did the recipient receive Hepatitis B vaccines prior to transplant? | |||
Pretransplant | CO L/min | Pretransplant | PA (sys)mm/Hg | |||
Pretransplant | CO L/min//Status | Value or status is reported, not both | Pretransplant | PA (sys)mm/Hg//Status | Value or status is reported, not both | |
Pretransplant | CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators | Pretransplant | PA(sys)mm/Hg Inotropes/VASODilators | |||
Pretransplant | Most Recent Serum Creatinine | Pretransplant | PA(dia) mm/Hg | |||
Pretransplant | Most Recent Serum Creatinine//Status | Value or status is reported, not both | Pretransplant | PA(dia) mm/HG//Status | Value or status is reported, not both | |
Pretransplant | Most Recent Total Bilirubin | Pretransplant | PA (dia) mm/Hg Inotropes/Vasodilators | |||
Pretransplant | Most Recent Total Bilirubin//Status | Value or status is reported, not both | Pretransplant | PA(mean) mm/Hg | ||
Pretransplant | Chronic Steroid Use | Pretransplant | PA(mean) mm/Hg//Status | Value or status is reported, not both | ||
Pretransplant | FVC | Pretransplant | PA (mean) mm/Hg Inotropes/Vasodilators | |||
Pretransplant | FVC % predicted//Status | Value or status is reported, not both | Pretransplant | PCW(mean) mm/Hg | ||
Pretransplant | FeV1 | Pretransplant | PCW(mean) mm/Hg//Status | Value or status is reported, not both | ||
Pretransplant | FeV1 % predicted//Status | Value or status is reported, not both | Pretransplant | PCW (mean) mm/Hg Inotropes/Vasodilators | ||
Pretransplant | pCO2 | Pretransplant | CO L/min | |||
Pretransplant | pCO2 mm/Hg//Status | Value or status is reported, not both | Pretransplant | CO L/min//Status | Value or status is reported, not both | |
Pretransplant | Transfusions | Pretransplant | CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators | |||
Pretransplant | Infection Requiring IV Therapy within 2 wks prior to Tx | Pretransplant | Most Recent Serum Creatinine | |||
Pretransplant | Dialysis | Pretransplant | Most Recent Serum Creatinine//Status | Value or status is reported, not both | ||
Pretransplant | Episode of Ventilatory Support | Pretransplant | Most Recent Total Bilirubin | |||
Pretransplant | If yes, indicate most recent timeframe | Pretransplant | Most Recent Total Bilirubin//Status | Value or status is reported, not both | ||
Pretransplant | Tracheostomy | Pretransplant | Chronic Steroid Use | |||
Transplant Procedure | Multiple Organ Recipient | Display Only - Cascades from feedback | Pretransplant | FVC | ||
Transplant Procedure | Were extra vessels used in the transplant procedure | Display Only - Cascades from feedback | Pretransplant | FVC % predicted//Status | Value or status is reported, not both | |
Transplant Procedure | Procedure Type | Display Only - Cascades from feedback | Pretransplant | FeV1 | ||
Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Left Lung | Pretransplant | FeV1 % predicted//Status | Value or status is reported, not both | ||
Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Left Lung//Status | Value or status is reported, not both | Pretransplant | pCO2 | ||
Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Right lung | Pretransplant | pCO2 mm/Hg//Status | Value or status is reported, not both | ||
Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Right Lung//Status | Value or status is reported, not both | Pretransplant | Transfusions | ||
Transplant Procedure | Lung(s) perfused prior to transplant? | Pretransplant | Infection Requiring IV Therapy within 2 wks prior to Tx | |||
Transplant Procedure | Perfusion occurred at: | Pretransplant | Dialysis | |||
Transplant Procedure | Perfusion performed by: | Pretransplant | Episode of Ventilatory Support | |||
Transplant Procedure | Total time on perfusion | Value or status is reported, not both | Pretransplant | If yes, indicate most recent timeframe | ||
Transplant Procedure | Lung(s) received at transplant center | Pretransplant | Tracheostomy | |||
Transplant Procedure | On ice | Pretransplant | Prior Thoracic Surgery other than prior transplant | |||
Transplant Procedure | On pump | Pretransplant | If yes, number of prior sternotomies | |||
Transplant Procedure | Right Lung/Enbloc: Stayed on pump Put on ice Left Lung: Stayed on pump Put on ice |
Pretransplant | If yes, number of prior thoracotomies | |||
Transplant Procedure | Organ Check-In Date | Pretransplant | Prior congenital cardiac surgery | |||
Transplant Procedure | Check-In Time | Pretransplant | If yes, palliative surgery | |||
Transplant Procedure | Check-In Time Zone | Display Only - Calculated | Pretransplant | If yes, corrective surgery | ||
Transplant Procedure | TransNet Organ Check-In Times for Related Organs | Display Only - Cascades from Database | Pretransplant | If yes, single ventricular physiology | ||
Post Transplant | Graft Status | Pretransplant | Most Recent Anti-A Titer | |||
Post Transplant | Date of Graft Failure | Pretransplant | Sample Date | |||
Post Transplant | Primary Cause of Graft Failure | Pretransplant | Most Recent Anti-B Titer | |||
Post Transplant | Primary Cause of Graft Failure// Other Specify | Pretransplant | Sample Date | |||
Post Transplant | Stroke | Transplant Procedure | Multiple Organ Recipient | Display Only - Cascades from feedback | ||
Post Transplant | Dialysis | Transplant Procedure | Were extra vessels used in the transplant procedure | Display Only - Cascades from feedback | ||
Post Transplant | Ventilator Support | Transplant Procedure | Procedure Type | Display Only - Cascades from feedback | ||
Post Transplant | Reintubated | Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Left Lung | |||
Post Transplant | Permanent Pacemaker | Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Left Lung//Status | Value or status is reported, not both | ||
Post Transplant | Airway Dehiscence | Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Right lung | |||
Post Transplant | Did patient have any acute rejection episodes between transplant and discharge | Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Right Lung//Status | Value or status is reported, not both | ||
Post Transplant | Intubated at 72 hours | Transplant Procedure | Lung(s) perfused prior to transplant? | |||
Post Transplant | PaO2 at 72 hours | Transplant Procedure | Perfusion occurred at: | |||
Post Transplant | PaO2 at 72 hours//Status | Value or status is reported, not both | Transplant Procedure | Perfusion performed by: | ||
Post Transplant | Fi02 at 72 hours | Transplant Procedure | Total time on perfusion | Value or status is reported, not both | ||
Post Transplant | FiO2 at 72 hours//Status | Value or status is reported, not both | Transplant Procedure | Lung(s) received at transplant center | ||
Post Transplant | ECMO a 72 hours | Transplant Procedure | On ice | |||
Post Transplant | Inhaled NO at 72 hours | Transplant Procedure | On pump | |||
Immunosuppression Other | Are any medications given currently for maintenance or anti-rejection | Transplant Procedure | Right Lung/Enbloc: Stayed on pump Put on ice Left Lung: Stayed on pump Put on ice |
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Immunosuppression Other | Immunosuppression medication | Transplant Procedure | Organ Check-In Date | |||
Immunosuppression Other | Immunosuppression medication indication | Transplant Procedure | Check-In Time | |||
Immunosuppression Other | Days of induction | Transplant Procedure | Check-In Time Zone | Display Only - Calculated | ||
Transplant Procedure | TransNet Organ Check-In Times for Related Organs | Display Only - Cascades from Database | ||||
Post Transplant | Graft Status | |||||
OMB No. 0915-0157; Expiration Date: XX/XX/20XX | Post Transplant | Date of Graft Failure | ||||
PUBLIC BURDEN STATEMENT: | Post Transplant | Primary Cause of Graft Failure | ||||
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]. |
Post Transplant | Primary Cause of Graft Failure//Other Specify | ||||
Post Transplant | Stroke | |||||
Post Transplant | Dialysis | |||||
Post Transplant | Ventilator Support | |||||
Post Transplant | Reintubated | |||||
Post Transplant | Permanent Pacemaker | |||||
Post Transplant | Airway Dehiscence | |||||
Post Transplant | Did patient have any acute rejection episodes between transplant and discharge | |||||
Post Transplant | Intubated at 72 hours | |||||
Post Transplant | PaO2 at 72 hours | |||||
Post Transplant | PaO2 at 72 hours//Status | Value or status is reported, not both | ||||
Post Transplant | Fi02 at 72 hours | |||||
Post Transplant | FiO2 at 72 hours//Status | Value or status is reported, not both | ||||
Post Transplant | ECMO a 72 hours | |||||
Post Transplant | Inhaled NO at 72 hours | |||||
Post Transplant | Most Recent Anti-A Titer | |||||
Post Transplant | Most Recent Anti-A Titer//Sample Date | |||||
Post Transplant | Most Recent Anti-B Titer | |||||
Post Transplant | Most Recent Anti-B Titer//Sample Date | |||||
Immunosuppression Other | Are any medications given currently for maintenance or anti-rejection | |||||
Immunosuppression Other | Immunosuppression medication | |||||
Immunosuppression Other | Immunosuppression medication indication | |||||
Immunosuppression Other | Days of induction | |||||
OMB No. 0915-0157; Expiration Date: XX/XX/20XX | ||||||
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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File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |