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 | Gender | Display Only - Cascades from TCR | Recipient Information | Gender | Display Only - Cascades from TCR | |
Recipient Information | Tx Date | Display Only - Cascades from feedback | Recipient Information | Tx Date | Display Only - Cascades from feedback | |
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 | |||
Patient Status | Medical Condition at time of transplant | Patient Status | Medical Condition at time of transplant | |||
Patient Status | Patient on Life Support | Patient Status | Patient on Life Support | |||
Patient Status | Extra Corporeal Membrane Oxygenation | Patient Status | Extra Corporeal Membrane Oxygenation | |||
Patient Status | Intra Aortic Balloon Pump | Patient Status | Prostaglandins | |||
Patient Status | Other Mechanism | Patient Status | Intravenous Inotropes | |||
Patient Status | Other Mechanism, Specify | Patient Status | Ventilator | |||
Patient Status | Prostacyclin Infusion | Patient Status | Inhaled NO | |||
Patient Status | Prostacyclin Inhalation | Patient Status | Other Mechanism | |||
Patient Status | Functional Status | Patient Status | Other Mechanism, Specify | |||
Patient Status | Working for income | Patient Status | Prostacyclin Infusion | |||
Patient Status | Primary Source of Payment | Patient Status | Prostacyclin Inhalation | |||
Patient Status | Primary Source of Payment, Specify | Patient Status | Life Support: VAD Brand1 | |||
Pretransplant | Height | Patient Status | Life Support: VAD Brand1//Specify | |||
Pretransplant | Height in Centimeters//Status | Value or status is reported, not both | Patient Status | Life Support: VAD Brand2 | ||
Pretransplant | Height Percentile//Growth Percentiles//%ile | Calculated for display only | Patient Status | Life Support: VAD Brand2//Specify | ||
Pretransplant | Weight | Patient Status | Functional Status | |||
Pretransplant | Weight in Kilograms//Status | Value or status is reported, not both | Patient Status | Academic Progress | ||
Pretransplant | Weight Percentile//Growth Percentiles//%ile | Calculated for display only | Patient Status | Academic Activity Level | ||
Pretransplant | BMI | Display Only - Cascades from Database | Patient Status | Primary Source of Payment | ||
Pretransplant | BMI://%ile | Calculated for display only | Patient Status | Primary Source of Payment, Specify | ||
Pretransplant | Previous Transplant Organ | Display Only - Cascades from Database | Patient Status | Cognitive Development | ||
Pretransplant | Previous Transplant Date | Display Only - Cascades from Database | Patient Status | 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 | Prior Cardiac Surgery (non-transplant) | Pretransplant | Most Recent Total Bilirubin | |||
Pretransplant | If yes, check all that apply | Pretransplant | Most Recent Total Bilirubin//Status | Value or status is reported, not both | ||
Pretransplant | Prior Cardiac Surgery//Specify | Pretransplant | Chronic Steroid Use | |||
Pretransplant | Prior Lung Surgery (non-transplant) | Pretransplant | FVC | |||
Pretransplant | If yes, check all that apply | Pretransplant | FVC % predicted//Status | Value or status is reported, not both | ||
Pretransplant | Prior Lung Surgery//Specify | Pretransplant | FeV1 | |||
Pretransplant | Episode of Ventilatory Support | Pretransplant | FeV1 % predicted//Status | Value or status is reported, not both | ||
Pretransplant | If yes, indicate most recent timeframe | Pretransplant | pCO2 | |||
Pretransplant | Tracheostomy | Pretransplant | pCO2 mm/Hg//Status | Value or status is reported, not both | ||
Transplant Procedure | Multiple Organ Recipient | Display Only - Cascades from feedback | Pretransplant | Transfusions | ||
Transplant Procedure | Were extra vessels used in the transplant procedure | Display Only - Cascades from feedback | Pretransplant | Infection Requiring IV Therapy within 2 wks prior to Tx | ||
Transplant Procedure | Procedure Type | Display Only - Cascades from feedback | Pretransplant | Dialysis | ||
Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Left Lung | Pretransplant | Episode of Ventilatory Support | |||
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 | If yes, indicate most recent timeframe | ||
Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Right lung | Pretransplant | Tracheostomy | |||
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 | Prior Thoracic Surgery other than prior transplant | ||
Transplant Procedure | Lung(s) perfused prior to transplant? | Pretransplant | If yes, number of prior sternotomies | |||
Transplant Procedure | Perfusion occurred at: | Pretransplant | If yes, number of prior thoracotomies | |||
Transplant Procedure | Perfusion performed by: | Pretransplant | Prior congenital cardiac surgery | |||
Transplant Procedure | Total time on perfusion | Pretransplant | If yes, palliative surgery | |||
Transplant Procedure | Lung(s) received at transplant center | Pretransplant | If yes, corrective surgery | |||
Transplant Procedure | On ice | Pretransplant | If yes, single ventricular physiology | |||
Transplant Procedure | On pump | Pretransplant | Most Recent Anti-A Titer | |||
Transplant Procedure | Right Lung/Enbloc: Stayed on pump Put on ice Left Lung: Stayed on pump Put on ice |
Pretransplant | Sample Date | |||
Post Transplant | Graft Status | Pretransplant | Most Recent Anti-B Titer | |||
Post Transplant | Date of Graft Failure | Pretransplant | Sample Date | |||
Post Transplant | Primary Cause of Graft Failure | Transplant Procedure | Multiple Organ Recipient | Display Only - Cascades from feedback | ||
Post Transplant | Primary Cause of Graft Failure// Other Specify | Transplant Procedure | Were extra vessels used in the transplant procedure | Display Only - Cascades from feedback | ||
Post Transplant | Stroke | Transplant Procedure | Procedure Type | Display Only - Cascades from feedback | ||
Post Transplant | Dialysis | Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Left Lung | |||
Post Transplant | Ventilator Support | 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 | Reintubated | Transplant Procedure | Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Right lung | |||
Post Transplant | Permanent Pacemaker | 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 | Airway Dehiscence | Transplant Procedure | Lung(s) perfused prior to transplant? | |||
Post Transplant | Did patient have any acute rejection episodes between transplant and discharge | Transplant Procedure | Perfusion occurred at: | |||
Post Transplant | Intubated at 72 hours | Transplant Procedure | Perfusion performed by: | |||
Post Transplant | PaO2 at 72 hours | Transplant Procedure | Total time on perfusion | |||
Post Transplant | PaO2 at 72 hours//Status | Value or status is reported, not both | Transplant Procedure | Lung(s) received at transplant center | ||
Post Transplant | Fi02 at 72 hours | Transplant Procedure | On ice | |||
Post Transplant | FiO2 at 72 hours//Status | Value or status is reported, not both | Transplant Procedure | On pump | ||
Post Transplant | ECMO a 72 hours | Transplant Procedure | Right Lung/Enbloc: Stayed on pump Put on ice Left Lung: Stayed on pump Put on ice |
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Post Transplant | Inhaled NO at 72 hours | Post Transplant | Graft Status | |||
Immunosupression Other | Are any medications given currently for maintenance or anti-rejection | Post Transplant | Date of Graft Failure | |||
Immunosupression Other | Immunosuppression medication | Post Transplant | Primary Cause of Graft Failure | |||
Immunosuppression Other | Immunosuppression medication indication | Post Transplant | Primary Cause of Graft Failure//Other Specify | |||
Immunosuppression Other | Days of induction | Post Transplant | Stroke | |||
Post Transplant | Dialysis | |||||
Post Transplant | Ventilator Support | |||||
Post Transplant | Reintubated | |||||
PUBLIC BURDEN STATEMENT: | Post Transplant | Permanent Pacemaker | ||||
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 0.7 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. |
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 | |||||
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 0.7 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. |
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File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |