20 Heart/Lung Transplant Recipient Follow Up 6 Month_Form.x

TRF (6-Month) - Heart/Lung - Adult and Pediatric
Fields to be completed by members
Form Section	Field label	Notes
Recipient Information	Organ Type	Display Only - Cascades from Database
Recipient Information	Follow-up code	Display Only - Cascades from Database
Recipient Information	Recipient First Name	Display Only Cascades from TCR
Recipient Information	Recipient Last Name	Display Only Cascades from TCR
Recipient Information	Recipient Middle Initial	Display Only Cascades from TCR
Recipient Information	SSN	Display Only - Cascades from TCR
Recipient Information	HIC	Display Only - Cascades from TCR
Recipient Information	Previous Follow-up	Display Only - Cascades from prior TRF
Recipient Information	Previous Px Stat Date	Display Only - Cascades from prior TRF
Recipient Information	Transplant Discharge Date
Recipient Information	DOB	Display Only - Cascades from TCR
Recipient Information	Gender	Display Only - Cascades from TCR
Recipient Information	Tx Date	Display Only - Cascades from Database
Recipient Information	State of Permanent Residence
Recipient Information	Zip Code
Provider Information	Recipient Center Type	Display Only - Cascades from TCR
Provider Information	Recipient Center	Display Only - Cascades from TCR
Provider Information	Follow-up Center Code	Display Only - Cascades from Database
Provider Information	Follow-up Center Type	Display Only - Cascades from Database
Donor Information	UNOS Donor ID #	Display Only - Cascades from Database
Donor Information	Donor Type	Display Only - Cascades from Database
Donor Information	OPO	Display Only - Cascades from feedback
Patient Status	Date: Last Seen, Retransplanted or Death
Patient Status	Patient Status
Patient Status	Primary Cause of Death
Patient Status	Primary Cause of Death//Specify
Patient Status	Contributory Cause of Death	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//Specify	Not required
Clinical Information	Heart Graft Status
Clinical Information	Heart Date of Graft Failure
Clinical Information	Heart Primary Cause of Graft Failure
Clinical Information	Heart Primary Cause of Graft Failure//Other, Specify
Clinical Information	Graft Status
Clinical Information	Date of Graft Failure
Clinical Information	Primary Cause of Graft Failure
Clinical Information	Primary Cause of Graft Failure// Other Specify
Clinical Information	Date Test Performed	Value or status is reported, not both
Clinical Information	FEV1	Value or status is reported, not both
Clinical Information	FVC	Value or status is reported, not both
Clinical Information	FEF 25-75	Value or status is reported, not both
Clinical Information	Date Test Performed	Value or status is reported, not both
Clinical Information	FEV1	Value or status is reported, not both
Clinical Information	FVC	Value or status is reported, not both
Clinical Information	FEF 25-75	Value or status is reported, not both
Clinical Information	Date Test Performed	Value or status is reported, not both
Clinical Information	FEV1	Value or status is reported, not both
Clinical Information	FVC	Value or status is reported, not both
Clinical Information	FEF 25-75	Value or status is reported, not both
Clinical Information	Current Supplemental O2 requirements at rest and/or at exercise
Clinical Information	At rest: FiO2 or Flow	Value or status is reported, not both
Clinical Information	With exercise: FiO2 or Flow	Value or status is reported, not both
Clinical Information	HIV Serology
Clinical Information	HIV NAT
Clinical Information	HbsAg
Clinical Information	HBV DNA
Clinical Information	HBV Core Antibody
Clinical Information	HCV Serology
Clinical Information	HCV NAT
Clinical Information	Most Recent Anti-A Titer
Clinical Information	Most Recent Anti-A Titer//Sample Date
Clinical Information	Most Recent Anti-B Titer
Clinical Information	Most Recent Anti-B Titer//Sample Date
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.