46 KidneyPancreas Transplant Recipient Registration_Form.xl

TRR - Kidney/Pancreas Adult
Fields to be completed by members							Fields to be completed by members
Form Section	Field Label	Notes		Form Section	Field Label	Notes
1- Recipient Information	Organ	Display Only - Cascades from TCR		1- Recipient Information	Organ	Display Only - Cascades from TCR
1- Recipient Information	Recipient First Name	Display Only - Cascades from TCR		1- Recipient Information	Recipient First Name	Display Only - Cascades from TCR
1- Recipient Information	Recipient Middle Initial	Not required		1- Recipient Information	Recipient Middle Initial	Not required
1- Recipient Information	Recipient Last Name	Display Only - Cascades from TCR		1- Recipient Information	Recipient Last Name	Display Only - Cascades from TCR
1- Recipient Information	SSN	Display Only - Cascades from TCR		1- Recipient Information	SSN	Display Only - Cascades from TCR
1- Recipient Information	HIC	Display Only - Cascades from TCR		1- Recipient Information	HIC	Display Only - Cascades from TCR
1- Recipient Information	DOB	Display Only - Cascades from TCR		1- Recipient Information	DOB	Display Only - Cascades from TCR
1- Recipient Information	Gender	Display Only - Cascades from TCR		1- Recipient Information	Gender	Display Only - Cascades from TCR
1- Recipient Information	Tx Date	Display Only - Cascades from feedback		1- Recipient Information	Tx Date	Display Only - Cascades from feedback
1- Recipient Information	State of Permanent Residence			1- Recipient Information	State of Permanent Residence
1- Recipient Information	Permanent Zip			1- Recipient Information	Permanent Zip
2- Provider Information	Recipient Center Code	Display Only - Cascades from TCR		2- Provider Information	Recipient Center Code	Display Only - Cascades from TCR
2- Provider Information	Recipient Center Type	Display Only - Cascades from TCR		2- Provider Information	Recipient Center Type	Display Only - Cascades from TCR
2- Provider Information	Surgeon Name			2- Provider Information	Surgeon Name
2- Provider Information	NPI#			2- Provider Information	NPI#
3- Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback		3- Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback
3- Donor Information	Donor Type	Display Only - Cascades from feedback		3- Donor Information	Donor Type	Display Only - Cascades from feedback
3- Donor Information	OPO	Display Only - Cascades from feedback		3- Donor Information	OPO	Display Only - Cascades from feedback
4-Patient Status	Kidney Primary Diagnosis			4-Patient Status	Kidney Primary Diagnosis
4-Patient Status	Kidney Primary Diagnosis//Specify			4-Patient Status	Kidney Primary Diagnosis//Specify
4-Patient Status	Pancreas Primary Diagnosis			4-Patient Status	Pancreas Primary Diagnosis
4-Patient Status	Pancreas Primary Diagnosis//Specify			4-Patient Status	Pancreas Primary Diagnosis//Specify
4-Patient Status	Date: Last Seen, Retransplanted or Death			4-Patient Status	Date: Last Seen, Retransplanted or Death
4-Patient Status	Patient Status			4-Patient Status	Patient Status
4-Patient Status	Primary Cause of Death			4-Patient Status	Primary Cause of Death
4-Patient Status	Cause of Death//Specify			4-Patient Status	Cause of Death//Specify
4-Patient Status	Contributory Cause of Death	Not required		4-Patient Status	Contributory Cause of Death	Not required
4-Patient Status	Contributory Cause of Death//Specify	Not required		4-Patient Status	Contributory Cause of Death//Specify	Not required
4-Patient Status	Contributory Cause of Death	Not required		4-Patient Status	Contributory Cause of Death	Not required
4-Patient Status	Contributory Cause of Death//Specify	Not required		4-Patient Status	Contributory Cause of Death//Specify	Not required
4-Patient Status	Retransplanted organ			4-Patient Status	Retransplanted organ
4-Patient Status	Date of Admission to Tx Center			4-Patient Status	Date of Admission to Tx Center
4-Patient Status	Date of Discharge from Tx Center	Not required		4-Patient Status	Date of Discharge from Tx Center
4-Patient Status	Functional Status			4-Patient Status	Functional Status
4-Patient Status	Working for income			4-Patient Status	Cognitive Development
4-Patient Status	Primary			4-Patient Status	Motor Development
4-Patient Status	Kidney Foreign Government//Specify			4-Patient Status	Academic Progress
4-Patient Status	Primary			4-Patient Status	Academic Activity Level
4-Patient Status	Pancreas Foreign Government//Specify			4-Patient Status	Primary
5- Pretransplant	Height			4-Patient Status	Kidney Foreign Government//Specify
5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both		4-Patient Status	Primary
5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		4-Patient Status	Pancreas Foreign Government//Specify
5- Pretransplant	Weight			5- Pretransplant	Date of Measurement
5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both		5- Pretransplant	Height
5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only		5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both
5- Pretransplant	BMI	Display Only - Cascades from Database		5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only
5- Pretransplant	BMI://%ile	Calculated for display only		5- Pretransplant	Weight
5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database		5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both
5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database		5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		5- Pretransplant	BMI	Display Only - Cascades from Database
5- Pretransplant	Pretransplant Dialysis			5- Pretransplant	BMI://%ile	Calculated for display only
5- Pretransplant	If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis			5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database
5- Pretransplant	Date First Dialyzed//Status	Value or status is reported, not both		5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database
5- Pretransplant	Average Daily Insulin Units			5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
5- Pretransplant	Average Daily Insulin Units//Status	Value or status is reported, not both		5- Pretransplant	Pretransplant Dialysis
5- Pretransplant	Serum Creatinine at Time of Tx			5- Pretransplant	If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis
5- Pretransplant	Serum Creatinine at Time of Tx//Status	Value or status is reported, not both		5- Pretransplant	Date First Dialyzed//Status	Value or status is reported, not both
5- Pretransplant	HIV Serostatus			5- Pretransplant	Average Daily Insulin Units
5- PreTransplant	NAT HIV			5- Pretransplant	Average Daily Insulin Units//Status	Value or status is reported, not both
5- Pretransplant	CMV Status			5- Pretransplant	Serum Creatinine at Time of Tx
5- Pretransplant	HBV Core Antibody			5- Pretransplant	Serum Creatinine at Time of Tx//Status	Value or status is reported, not both
5- Pretransplant	HBV Surface Antibody Total			5- Pretransplant	HIV Serostatus
5- Pretransplant	HBV Surface Antigen			5- PreTransplant	NAT HIV
5- PreTransplant	NAT HBV			5- Pretransplant	CMV Status
5- Pretransplant	HCV Serostatus			5- Pretransplant	HBV Core Antibody
5- PreTransplant	NAT HCV			5- Pretransplant	HBV Surface Antibody Total
5- Pretransplant	EBV Serostatus			5- Pretransplant	HBV Core Antibody
5- Pretransplant	Previous Pregnancies			5- Pretransplant	HBV Surface Antigen
5- Pretransplant	Malignancies between listing and transplant//Specify			5- PreTransplant	NAT HBV
5- Pretransplant	Malignancies between listing and transplant			5- Pretransplant	HCV Serostatus
5- Pretransplant	If yes, specify type			5- PreTransplant	NAT HCV
6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		5- Pretransplant	EBV Serostatus
6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback		5- Pretransplant	Malignancies between listing and transplant//Specify
6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		5- Pretransplant	Malignancies between listing and transplant
6-Transplant Procedure	Graft Placement			5- Pretransplant	If yes, specify type
6-Transplant Procedure	Operative Technique			5- Pretransplant	Fracture in the past year (or since last follow-up)
6-Transplant Procedure	Duct Management			5- Pretransplant	Spine-compression fracture
6-Transplant Procedure	Duct Management//Specify			5- Pretransplant	Spine-compression fracture//# of fractures
6-Transplant Procedure	Venous Vascular Management			5- Pretransplant	Extremity
6-Transplant Procedure	Arterial Reconstruction			5- Pretransplant	Extremity//# of fractures
6-Transplant Procedure	Arterial Reconstruction//Specify			5- Pretransplant	Other
6-Transplant Procedure	Venous Extension Graft			5- Pretransplant	Other//# of fractures
6-Transplant Procedure	Total Cold ischemia Time Right KI(OR EN-BLOC): (if pumped, include pump time)			5- Pretransplant	AVN (avascular necrosis)
6-Transplant Procedure	Total Cold Ischemia Time Right KI//Status	Value or status is reported, not both		6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
6-Transplant Procedure	Total Cold Ischemia Time Left KI (If pumped, include pump time)			6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
6-Transplant Procedure	Total Cold Ischemia Time Left KI//Status	Value or status is reported, not both		6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)			6-Transplant Procedure	Operative Technique
6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)//Status	Value or status is reported, not both		6-Transplant Procedure	Duct Management
6-Transplant Procedure	Kidney(s) received on			6-Transplant Procedure	Duct Management//Specify
6-Transplant Procedure	Received on ice			6-Transplant Procedure	Venous Vascular Management
6-Transplant Procedure	Received on pump			6-Transplant Procedure	Arterial Reconstruction
6-Transplant Procedure	Left Kidney Final resistance at transplant			6-Transplant Procedure	Arterial Reconstruction//Specify
6-Transplant Procedure	Left Kidney Final resistance at tx//Status	Value or status is reported, not both		6-Transplant Procedure	Venous Extension Graft
6-Transplant Procedure	Right Kidney Final resistance at transplant			6-Transplant Procedure	Total Cold ischemia Time Right KI(OR EN-BLOC): (if pumped, include pump time)
6-Transplant Procedure	Right Kidney Final resistance at tx//Status	Value or status is reported, not both		6-Transplant Procedure	Total Cold Ischemia Time Right KI//Status	Value or status is reported, not both
6-Transplant Procedure	Left Kidney Final flow rate at transplant			6-Transplant Procedure	Total Cold Ischemia Time Left KI (If pumped, include pump time)
6-Transplant Procedure	Left Kidney Final flow rate at tx//Status	Value or status is reported, not both		6-Transplant Procedure	Total Cold Ischemia Time Left KI//Status	Value or status is reported, not both
6-Transplant Procedure	Right Kidney Final flow rate at transplant			6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)
6-Transplant Procedure	Right Kidney Final flow rate at tx//Status	Value or status is reported, not both		6-Transplant Procedure	Total Pancreas Preservation Time (include Cold, Warm, Anastomotic time)//Status	Value or status is reported, not both
7- Post Transplant	Graft Status			6-Transplant Procedure	Kidney(s) received on
7- PostTransplant	Resumed Maintenance Dialysis			6-Transplant Procedure	Received on ice
7- PostTransplant	Date Maintenance Dialysis Resumed			6-Transplant Procedure	Received on pump
7- Post Transplant	Date of Graft Failure:			6-Transplant Procedure	Left Kidney Final resistance at transplant
7- Post Transplant	Primary Cause of Graft Failure:			6-Transplant Procedure	Left Kidney Final resistance at tx//Status	Value or status is reported, not both
7- Post Transplant	Primary Cause of Graft Failure//Other, Specify:			6-Transplant Procedure	Right Kidney Final resistance at transplant
7- PostTransplant	Did patient have any acute kidney rejection episodes between transplant and discharge			6-Transplant Procedure	Right Kidney Final resistance at tx//Status	Value or status is reported, not both
7- PostTransplant	Most Recent Serum Creatinine Prior to Discharge			6-Transplant Procedure	Left Kidney Final flow rate at transplant
7- PostTransplant	Most Recent Serum Creatinine Prior to Discharge//Status	Value or status is reported, not both		6-Transplant Procedure	Left Kidney Final flow rate at tx//Status	Value or status is reported, not both
7- PostTransplant	Patient Need Dialysis within First Week			6-Transplant Procedure	Right Kidney Final flow rate at transplant
7- PostTransplant	Pancreas Graft Status			6-Transplant Procedure	Right Kidney Final flow rate at tx//Status	Value or status is reported, not both
7- Post Transplant	Patient using any method of blood sugar control?			7- Post Transplant	Graft Status
7- Post Transplant	Patient on insulin?	New field if pancreas graft status is functioning. Modified label if graft status is failed		7- Post Transplant	Resumed Maintenance Dialysis
7- Post Transplant	Date insulin resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed		7- Post Transplant	Date Maintenance Dialysis Resumed
7- Post Transplant	Total insulin dosage units			7- Post Transplant	Date of Graft Failure:
7- Post Transplant	Total insulin dosage units//ST	Value or status is reported, not both		7- PostTransplant	Primary Cause of Graft Failure:
7- Post Transplant	Insulin duration of use			7- PostTransplant	Primary Cause of Graft Failure//Other, Specify:
7- Post Transplant	Insulin duration of use//ST	Value or status is reported, not both		7- PostTransplant	Did patient have any acute kidney rejection episodes between transplant and discharge
7- Post Transplant	Patient on oral medication to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed		7- PostTransplant	Is growth hormone therapy used between listing and transplant
7- Post Transplant	Date oral medications resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed		7- PostTransplant	Most Recent Serum Creatinine Prior to Discharge
7- Post Transplant	Patient using diet to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed		7- PostTransplant	Most Recent Serum Creatinine Prior to Discharge//Status	Value or status is reported, not both
7- PostTransplant	Pancreas Date of Graft Failure			7- PostTransplant	Patient Need Dialysis within First Week
7- Post Transplant	C-Peptide Value			7- PostTransplant	Pancreas Graft Status
7- Post Transplant	C-Peptide Value://ST=	Value or status is reported, not both		7- Post Transplant	Patient using any method of blood sugar control?
7- Post Transplant	Hba1c (%)			7- Post Transplant	Patient on insulin?	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- Post Transplant	Hba1c (%)//Status	Value or status is reported, not both		7- Post Transplant	Date insulin resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Pancreas Primary Cause of Graft Failure			7- Post Transplant	Total insulin dosage units
7- PostTransplant	Pancreas Primary Cause of Graft Failure/Specify			7- Post Transplant	Total insulin dosage units//ST	Value or status is reported, not both
7- PostTransplant	Pancreas Graft/Vascular Thrombosis			7- Post Transplant	Insulin duration of use
7- PostTransplant	Pancreas Infection			7- Post Transplant	Insulin duration of use//ST	Value or status is reported, not both
7- PostTransplant	Bleeding			7- Post Transplant	Patient on oral medication to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Anastomotic Leak			7- Post Transplant	Date oral medications resumed	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Hyperacute Rejection			7- Post Transplant	Patient using diet to control blood sugar	New field if pancreas graft status is functioning. Modified label if graft status is failed
7- PostTransplant	Pancreas Acute Rejection			7- PostTransplant	Pancreas Date of Graft Failure
7- PostTransplant	Biopsy Proven Isletitis			7- Post Transplant	C-Peptide Value
7- PostTransplant	Pancreatitis			7- Post Transplant	C-Peptide Value://ST=	Value or status is reported, not both
7- PostTransplant	Other, Specify			7- Post Transplant	Hba1c (%)
7- PostTransplant	Did patient have any acute pancreas rejection episodes between transplant and discharge			7- Post Transplant	Hba1c (%)//Status	Value or status is reported, not both
7- PostTransplant	Pancreatitis			7- PostTransplant	Pancreas Primary Cause of Graft Failure
7- PostTransplant	Anastomotic Leak			7- PostTransplant	Pancreas Primary Cause of Graft Failure/Specify
7- PostTransplant	Abscess or Local Infection			7- PostTransplant	Pancreas Graft/Vascular Thrombosis
7- PostTransplant	Other	Not required		7- PostTransplant	Pancreas Infection
7- PostTransplant	Weight Post Transplant			7- PostTransplant	Bleeding
7- PostTransplant	Weight in Kilograms//Status	Value or status is reported, not both		7- PostTransplant	Anastomotic Leak
9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection			7- PostTransplant	Hyperacute Rejection
9- Immunosupression Other	immunosuppression medication			7- PostTransplant	Pancreas Acute Rejection
9- Immunosupression Other	immunosuppression medication indication			7- PostTransplant	Biopsy Proven Isletitis
9- Immunosupression Other	days of induction			7- PostTransplant	Pancreatitis
				7- PostTransplant	Other, Specify
				7- PostTransplant	Did patient have any acute pancreas rejection episodes between transplant and discharge
PUBLIC BURDEN STATEMENT:				7- PostTransplant	Pancreatitis
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/20xx. 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 3 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 paperwork@hrsa.gov.				7- PostTransplant	Anastomotic Leak
				7- PostTransplant	Abscess or Local Infection
				7- PostTransplant	Other	Not required
				7- PostTransplant	Weight Post Transplant
				7- PostTransplant	Weight in Kilograms//Status	Value or status is reported, not both
				9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection
				9- Immunosupression Other	immunosuppression medication
				9- Immunosupression Other	immunosuppression medication indication
				9- Immunosupression Other	days of induction
				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/20xx. 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 3 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 paperwork@hrsa.gov.