Document
Liver
ICR 202506-0915-004 · OMB 0915-0157 · Object 159264001.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | Liver |
| Author | Windows User |
| Last Modified By | Calc |
| File Modified | 2025-05-23 |
| File Created | 2026-09-14 |
| Conversion State | complete |
Extracted Text
TRF (6 Month - 5 Year) - Liver - Adult Fields to be completed by members Form Section Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Provider Information Provider Information Provider Information Provider Information Provider Information Provider Information Provider Information Provider Information Donor Information Donor Information Donor Information Patient Status Patient Status Patient Status Patient Status Patient Status Patient Status Patient Status Patient Status Patient Status Patient Status Field Label Organ Type Follow-up code Recipient First Name Recipient Last Name Recipient Middle Initial SSN HIC Previous Follow-up DOB Gender Birth Sex Tx Date Previous Px Stat Date Transplant Discharge Date State of Permanent Residence Zip Code Recipient Center Recipient Center Type Follow-up Center Code Follow-up Center Type Physician Name NPI# Follow-up Care Provided By Follow-up Care Provided By//Specify UNOS Donor ID # Donor Type OPO Date: Last Seen, Retransplanted or Death Patient Status Primary Cause of Death Primary Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Has the patient been hospitalized since the last patient status date Functional Status Notes Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from prior TRF Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from Database Display Only - Cascades from prior TRF Patient Status Working for income Patient Status Patient Status Patient Status at Time of Follow-up Patient Status Patient Status Primary Insurance at Follow-up Primary Source of Payment, Specify Patient Status at Time of Follow-up Patient Status Clinical Information Pathology confirmed liver diagnosis at hospital discharge Patient Status Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Pathology confirmed liver diagnosis at hospital discharge HIV Serology HIV NAT HbsAg HBV DNA HBV Core Antibody HCV Serology HCV NAT Graft Status Date of Failure Primary Non-Function Hepatic Artery Thrombosis Other Vascular Thrombosis Patient Status Patient Status Patient Status Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Hepatic outflow obstruction Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Portal vein thrombosis Diffuse Cholangiopathy Hepatitis: DeNovo Hepatitis: Recurrent Recurrent Disease (non-Hepatitis) Acute Rejection Infection Other, Specify Lab Date Total Bilirubin Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from feedback Not required Not required Not required Not required _x000D_ OPTN Restricted # Form Section Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Recipient Information Provider Information Provider Information Provider Information Provider Information Provider Information Provider Information Provider Information Provider Information Donor Information Donor Information Donor Information Patient Status Patient Status Patient Status Patient Status Patient Status Patient Status Patient Status Patient Status Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Immunosuppressive Information Immunosuppressive Information Immunosuppressive Information Immunosuppressive Information Total Bilirubin://Status Value or status is reported, not both Most Recent Serum Creatinine Most Recent Serum Creatinine://Status Value or status is reported, not both New diabetes onset between last follow-up to the current follow-up Insulin dependent Did patient have any acute rejection episodes during the follow-up period Post Transplant Malignancy Donor Related Recurrence of Pre-Tx Tumor De Novo Solid Tumor De Novo Lymphoproliferative disease and Lymphoma Were any medications given during the follow-up period for maintenance Clinical Information Clinical Information Clinical Information Previous Validated Maintenance Follow-up Medications Display Only - Cascades from Database Clinical Information Immunosuppression medication Clinical Information Immunosuppression medication indication Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Immunosuppressive Information Immunosuppressive Information Immunosuppressive Information Immunosuppressive Information OMB No. 0915-0157; Expiration Date: XX/XX/20XX PUBLIC BURDEN STATEMENT: The private, non-profit Organ Procurement and Trans the following OPTN functions: to assess whether appl to monitor compliance of member organizations with not required to respond to, a collection of information control number for this information collection is 0915 required to obtain or retain a benefit per 42 CFR §121 (Privacy Act System of Records #09-15-0055). Data co number of the Contractor’s security features. The Con prescribed by OMB Circular A-130, Appendix III, Secur Automated Information Systems Security Program Ha estimated to average 0.27 hours per response, includ and completing and reviewing the collection of inform of this collection of information, including suggestions Officer, 5600 Fishers Lane, Room 14N39, Rockville, M _x000D_ OPTN Restricted # TRF (6 Month - 5 Year) - Liver - Pediatric Fields to be completed by members Field Label Organ Type Follow-up code Recipient First Name Recipient Last Name Recipient Middle Initial SSN HIC Previous Follow-up DOB Gender Birth Sex Tx Date Previous Px Stat Date Transplant Discharge Date State of Permanent Residence Zip Code Recipient Center Recipient Center Type Follow-up Center Code Follow-up Center Type Physician Name NPI# Follow-up Care Provided By Follow-up Care Provided By//Specify UNOS Donor ID # Donor Type OPO Date: Last Seen, Retransplanted or Death Patient Status Primary Cause of Death Primary Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Contributory Cause of Death Contributory Cause of Death//Specify Has the patient been hospitalized since the last patient status date Functional Status Notes Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from prior TRF Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from Database Display Only - Cascades from prior TRF Display Only - Cascades from TCR Display Only - Cascades from TCR Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from Database Display Only - Cascades from feedback Not required Not required Not required Not required Cognitive Development Motor Development Working for income Academic Progress Academic Activity Level Primary Insurance at Follow-up Primary Source of Payment, Specify Height Measurement Date Height Height//Status Height Percentile Weight Measurement Date Weight Weight//Status Weight Percentile BMI BMI://%ile Pathology confirmed liver diagnosis at hospital discharge Pathology confirmed liver diagnosis at hospital discharge HIV Serology HIV NAT HbsAg HBV DNA HBV Core Antibody HCV Serology HCV NAT Graft Status Date of Failure Value or status is reported, not both Calculated for display only Value or status is reported, not both Calculated for display only Display Only - Cascades from Database Calculated for display only _x000D_ OPTN Restricted # Primary Non-Function Hepatic Artery Thrombosis Other Vascular Thrombosis Hepatic Outflow Obstruction Portal Vein Thrombosis Diffuse Cholangiopathy Hepatitis: DeNovo Hepatitis: Recurrent Recurrent Disease (non-Hepatitis) Acute Rejection Infection Other, Specify Lab Date Total Bilirubin Total Bilirubin://Status Value or status is reported, not both Most Recent Serum Creatinine Most diabetes Recent Serum Creatinine://Status New onset between last follow-up Value or status is reported, not both to the current follow-up Insulin dependent Did patient have any acute rejection episodes during the follow-up period Post Transplant Malignancy Donor Related Recurrence of Pre-Tx Tumor De Novo Solid Tumor De Novo Lymphoproliferative disease and Lymphoma Were any medications given during the follow-up period for maintenance Previous Validated Maintenance Follow-up Display Only - Cascades from Database Medications Immunosuppression medication Immunosuppression medication indication 15-0157; Expiration Date: XX/XX/20XX DEN STATEMENT: non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform g OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and ompliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB ber for this information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a he Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as y OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments nformation Systems Security Program Handbook. The public reporting burden for this collection of information is average 0.27 hours per response, including the time for reviewing instructions, searching existing data sources, ting and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect tion of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance 0 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. _x000D_ OPTN Restricted #