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.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|