25 Liver Transplant Recipient Registration_Form_clean.xlsx

TRR - Liver - Adults					TRR - Liver - Pediatrics
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	Surgeon Name			Provider Information	Surgeon Name
Provider Information	NPI#			Provider Information	NPI#
Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback		Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback
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	Patient on Life Support			Patient Status	Medical Condition at time of transplant
Patient Status	Ventilator			Patient Status	Patient on Life Support
Patient Status	Artificial Liver			Patient Status	Ventilator
Patient Status	Other Mechanism			Patient Status	Artificial Liver
Patient Status	Other Mechanism, Specify			Patient Status	Other Mechanism
Patient Status	Functional Status			Patient Status	Other Mechanism, Specify
Patient Status	Working for income			Patient Status	Functional Status
Patient Status	Primary Source of Payment			Patient Status	Working for income
Patient Status	Primary Source of Payment, Specify			Patient Status	Academic Progress
Pretransplant	Height			Patient Status	Academic Activity Level
Pretransplant	Height in Centimeters//Status	Value or status is reported, not both		Patient Status	Primary Source of Payment
Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		Patient Status	Primary Source of Payment, Specify
Pretransplant	Weight			Patient Status	Cognitive Development
Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both		Patient Status	Motor Development
Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only		Pretransplant	Date of Measurement
Pretransplant	BMI	Display Only - Cascades from Database		Pretransplant	Height
Pretransplant	BMI://%ile	Calculated for display only		Pretransplant	Height in Centimeters//Status	Value or status is reported, not both
Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database		Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only
Pretransplant	Previous Transplant Date	Display Only - Cascades from Database		Pretransplant	Weight
Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both
Pretransplant	HIV Serostatus			Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
Pretransplant	NAT HIV			Pretransplant	BMI	Display Only - Cascades from Database
Pretransplant	CMV Status			Pretransplant	BMI://%ile	Calculated for display only
Pretransplant	HBV Core Antibody			Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database
Pretransplant	HBV Surface Antibody Total			Pretransplant	Previous Transplant Date	Display Only - Cascades from Database
Pretransplant	HBV Core Antibody			Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
Pretransplant	HBV Surface Antigen			Pretransplant	HIV Serostatus
Pretransplant	NAT HBV			Pretransplant	NAT HIV
Pretransplant	HCV Serostatus			Pretransplant	CMV Status
Pretransplant	NAT HCV			Pretransplant	HBV Core Antibody
Pretransplant	EBV Serostatus			Pretransplant	HBV Surface Antibody Total
Pretransplant	Did the recipient receive Hepatitis B vaccines prior to transplant?			Pretransplant	HBV Core Antibody
Pretransplant	Has the recipient ever had a diagnosis of HCC?			Pretransplant	HBV Surface Antigen
Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		Pretransplant	NAT HBV
Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback		Pretransplant	HCV Serostatus
Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		Pretransplant	NAT HCV
Transplant Procedure	Split Type			Pretransplant	EBV Serostatus
Transplant Procedure	Total Cold Ischemia Time (if pumped, include pump time)			Pretransplant	Did the recipient receive Hepatitis B vaccines prior to transplant?
Transplant Procedure	Total Cold Ischemia Time (if pumped, include pump time)://Status	Value or status is reported, not both		Pretransplant	Has the recipient ever had a diagnosis of HCC?
Transplant Procedure	Previous Abdominal Surgery			Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
Transplant Procedure	Portal Vein Thrombosis			Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
Transplant Procedure	Transjugular Intrahepatic Portacaval Stint Shunt			Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
Post Transplant	Pathology Conf. Liver Diag. of Hospital Discharge			Transplant Procedure	Split Type
Post Transplant	If Other Pathology Conf. Liver Diag. of Hospital Discharge//Specify			Transplant Procedure	Total Cold Ischemia Time (if pumped, include pump time)
Post Transplant	Graft Status			Transplant Procedure	Total Cold Ischemia Time (if pumped, include pump time)://Status	Value or status is reported, not both
Post Transplant	Date of Graft Failure			Transplant Procedure	Previous Abdominal Surgery
Post Transplant	Primary Non-Function			Transplant Procedure	Portal Vein Thrombosis
Post Transplant	Hepatic Artery Thrombosis			Transplant Procedure	Transjugular Intrahepatic Portacaval Stint Shunt
Post Transplant	Other Vascular Thrombosis			Post Transplant	Pathology Conf. Liver Diag. of Hospital Discharge
Post Transplant	Hepatic outflow obstruction			Post Transplant	If Other Pathology Conf. Liver Diag. of Hospital Discharge//Specify
Post Transplant	Portal vein thrombosis			Post Transplant	Graft Status
Post Transplant	Diffuse Cholangiopathy			Post Transplant	Date of Graft Failure
Post Transplant	Hepatitis: DeNovo			Post Transplant	Primary Non-Function
Post Transplant	Hepatitis: Recurrent			Post Transplant	Hepatic Artery Thrombosis
Post Transplant	Recurrent Disease (non-Hepatitis)			Post Transplant	Other Vascular Thrombosis
Post Transplant	Acute Rejection			Post Transplant	Hepatic outflow obstruction
Post Transplant	Infection			Post Transplant	Portal vein thrombosis
Post Transplant	Other, Specify			Post Transplant	Diffuse Cholangiopathy
Post Transplant	Did patient have any acute rejection episodes between transplant and discharge			Post Transplant	Hepatitis: DeNovo
Immunosuppression Other	Are any medications given currently for maintenance or anti-rejection			Post Transplant	Hepatitis: Recurrent
Immunosuppression Other	Immunosuppression medication			Post Transplant	Recurrent Disease (non-Hepatitis)
Immunosuppression Other	Immunosuppression medication indication			Post Transplant	Acute Rejection
Immunosuppression Other	Days of induction			Post Transplant	Infection
				Post Transplant	Other, Specify
				Post Transplant	Did patient have any acute rejection episodes between transplant and discharge
PUBLIC BURDEN STATEMENT:				Immunosuppression Other	Are any medications given currently for maintenance or anti-rejection
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.				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.