Intestine

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TCR - Intestine - Adult
Fields to be completed by members
Form Section
Provider Information

Intestine Medical Factors
Intestine Medical Factors
Intestine Medical Factors

Field Label
Transplant Center Code
Transplant Center Type://Recipient
Center
Organ Registered:
Date of Listing or Add:
Last Name:
First Name:
Middle Initial://MI:
Previous Surname:
SSN:
Gender Birth Sex:
HIC:
Date of Birth://DOB:
State of Permanent Residence:
Permanent ZIP Code:
Ethnicity:
Race:
Citizenship:
Year of Entry to the U.S.
Year of Entry to the U.S Status//ST=
Country of Permanent Residence
Highest Education Level:
Patient on Life Support:
Life Support://Ventilator
Life Support://Artificial Liver
Life Support://Other Mechanism,
Specify
Life Support:Other
Mechanism//Specify:
Functional Status:
Working for income:
Previous Transplant//Organ
Previous Transplant//Date
Previous Transplant//Graft Fail Date
Previous Pancreas Islet Infusion:
Source of Payment//Primary:
Foreign Government//Specify:
Height in cm://Height:
Height Status//ST=
Height Growth percentiles//%ile
Weight in kg://Weight:
Weight Status//ST=
Weight Growth percentiles//%ile
BMI:
BMI://%ile
ABO Blood Group:
Primary Diagnosis:
Primary Diagnosis//Specify:
Diabetes:
Any previous Malignancy:
Any previous Malignancy//Specify
Type:
Any previous Malignancy//Specify:
Total Bilirubin
Variceal Bleeding within Last Two
Weeks:
Recurrent sepsis:
Fungal sepsis:

Intestine Medical Factors
Intestine Medical Factors

Unmanageable fluid-electrolyte losses:
"Non-Reconstructible" GI tract:

Provider Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Source of Payment
Source of Payment
Clinical Information
Clinical Information
Clinical Information
Clinical Information
Clinical Information
Clinical Information
Clinical Information
Clinical Information
Clinical Information
Clinical Information
Clinical Information
General Medical Factors
General Medical Factors
General Medical Factors
General Medical Factors
General Medical Factors

TCR - Intesti
Fields to be comp

Notes
Display Only - Cascades from Waitlist

Form Section
Provider Information

Display Only - Cascades from Waitlist
Display Only - Cascades from Waitlist
Display Only - Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist
Not required
Not required
Display Only - Cascades from Waitlist
Cascades from Waitlist
Not required
Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist

Provider Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Candidate Information
Patient Status
Patient Status
Patient Status
Patient Status

Display Only - Cascades from Database
Display Only - Cascades from Database
Display Only - Cascades from Database

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
Display Only - Cascades from Waitlist

Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Patient Status
Source of Payment
Source of Payment
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
Clinical Information
Clinical Information
General Medical Factors
General Medical Factors
General Medical Factors
General Medical Factors
General Medical Factors
General Medical Factors

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

Intestine Medical Factors

PUBLIC BURDEN STATEMENT:

Intestine Medical Factors

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,
_x000D_ OPTN
Restricted
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].
#

Intestine Medical Factors
Intestine Medical Factors
Intestine Medical Factors
Intestine Medical Factors
Intestine Medical Factors

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].

_x000D_ OPTN Restricted
#

OMB No. 0915-0157; Expiration Date: XX/XX/20XX
PUBLIC BURDEN STATEMENT:
The private, non-profit Organ Procurement and Transplantation
the following OPTN functions: to assess whether applicants mee
to monitor compliance of member organizations with OPTN Obli
not required to respond to, a collection of information unless it d
control number for this information collection is 0915-0157 and
required to obtain or retain a benefit per 42 CFR §121.11(b)(2). A
(Privacy Act System of Records #09-15-0055). Data collected by t
number of the Contractor’s security features. The Contractor’s se
prescribed by OMB Circular A-130, Appendix III, Security of Fede
Automated Information Systems Security Program Handbook. Th
estimated to average 0.27 hours per response, including the time
and completing and reviewing the collection of information. Sen
of this collection of information, including suggestions for reduci
Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20

TCR - Intestine - Pediatric
Fields to be completed by members
Field Label
Transplant Center Code
Transplant Center Type://Recipient
Center
Organ Registered:
Date of Listing or Add:
Last Name:
First Name:
Middle Initial://MI:
Previous Surname:
SSN:
Gender Birth Sex:
HIC:
Date of Birth://DOB:
State of Permanent Residence:
Permanent ZIP Code:
Ethnicity:
Race:
Citizenship:
Year of Entry to the U.S.
Year of Entry to the U.S Status//ST=
Country of Permanent Residence
Highest Education Level:
Patient on Life Support:
Life Support://Ventilator
Life Support://Artificial Liver
Life Support://Other Mechanism,
Specify
Life Support:Other
Mechanism//Specify:
Functional Status:
Cognitive Development:
Motor Development:
Academic Progress:
Academic Activity Level:
Previous Transplant//Organ
Previous Transplant//Date
Previous Transplant//Graft Fail Date
Source of Payment//Primary:
Foreign Government//Specify:
Height Measurement Date
Height in cm://Height:
Height Status//ST=
Height Growth percentiles//%ile
Weight Measurement Date
Weight in kg://Weight:
Weight Status//ST=
Weight Growth percentiles//%ile
BMI:
BMI://%ile
ABO Blood Group:
Primary Diagnosis:
Primary Diagnosis//Specify:
Secondary Diagnosis:

Notes
Display Only - Cascades from Waitlist
Display Only - Cascades from Waitlist
Display Only - Cascades from Waitlist
Display Only - Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist
Not required
Not required
Display Only - Cascades from Waitlist
Cascades from Waitlist
Not required
Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist
Cascades from Waitlist

Display Only - Cascades from Database
Display Only - Cascades from Database
Display Only - Cascades from Database

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
Display Only - Cascades from Waitlist

Not required

Secondary Diagnosis//Specify:
Diabetes:
Any previous Malignancy:
Any previous Malignancy//Specify
Type:
Any previous Malignancy//Specify:
Total Bilirubin:
Total Bilirubin://ST=
Value or status is reported, not both
Loss of two or more vascular access
sites:
History of Portomesenteric Vein
Thrombosis:
Variceal Bleeding within Last Two
Weeks:
Recurrent sepsis:
Fungal sepsis:
Unmanageable fluid-electrolyte losses:
"Non-Reconstructible" GI tract:

_x000D_ OPTN Restricted
#

7; Expiration Date: XX/XX/20XX

ofit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform
functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and
nce of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is
pond to, a collection of information unless it displays a currently valid OMB control number. The OMB
this information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is
or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection
m of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a
tractor’s security features. The Contractor’s security system meets or exceeds the requirements as
Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments
ation Systems Security Program Handbook. The public reporting burden for this collection of information is
ge 0.27 hours per response, including the time for reviewing instructions, searching existing data sources,
d reviewing the collection of information. Send comments regarding this burden estimate or any other aspect
information, including suggestions for reducing this burden, to HRSA Information Collection Clearance
s Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected].

_x000D_ OPTN Restricted
#