TRF - Kidney - Adult |
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TRF - Kidney - Pediatric |
Fields to be completed by members |
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Fields to be completed by members |
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Form Section |
Field label |
Notes |
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Form Section |
Field label |
Notes |
Recipient Information |
Organ Type |
Display Only - Cascades from Database |
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Recipient Information |
Organ Type |
Display Only - Cascades from Database |
Recipient Information |
Follow-up code |
Display Only - Cascades from Database |
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Recipient Information |
Follow-up code |
Display Only - Cascades from Database |
Recipient Information |
Recipient First Name |
Display Only - Cascades from TCR |
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Recipient Information |
Recipient First Name |
Display Only - Cascades from TCR |
Recipient Information |
Recipient Last Name |
Display Only - Cascades from TCR |
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Recipient Information |
Recipient Last Name |
Display Only - Cascades from TCR |
Recipient Information |
Recipient Middle Initial |
Display Only - Cascades from TCR |
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Recipient Information |
Recipient Middle Initial |
Display Only - Cascades from TCR |
Recipient Information |
SSN |
Display Only - Cascades from TCR |
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Recipient Information |
SSN |
Display Only - Cascades from TCR |
Recipient Information |
HIC |
Display Only - Cascades from TCR |
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Recipient Information |
HIC |
Display Only - Cascades from TCR |
Recipient Information |
Previous Follow-up |
Display Only - Cascades from prior TRF |
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Recipient Information |
Previous Follow-up |
Display Only - Cascades from prior TRF |
Recipient Information |
DOB |
Display Only - Cascades from TCR |
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Recipient Information |
DOB |
Display Only - Cascades from TCR |
Recipient Information |
Gender |
Display Only - Cascades from TCR |
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Recipient Information |
Gender |
Display Only - Cascades from TCR |
Recipient Information |
Tx Date |
Display Only - Cascades from Database |
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Recipient Information |
Tx Date |
Display Only - Cascades from Database |
Recipient Information |
Previous Px Stat Date |
Display Only - Cascades from prior TRF |
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Recipient Information |
Previous Px Stat Date |
Display Only - Cascades from prior TRF |
Recipient Information |
Transplant Discharge Date |
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Recipient Information |
Transplant Discharge Date |
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Recipient Information |
State of Permanent Residence |
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Recipient Information |
State of Permanent Residence |
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Recipient Information |
Zip Code |
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Recipient Information |
Zip Code |
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Provider Information |
Recipient Center |
Display Only - Cascades from TCR |
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Provider Information |
Recipient Center |
Display Only - Cascades from TCR |
Provider Information |
Recipient Center Type |
Display Only - Cascades from TCR |
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Provider Information |
Recipient Center Type |
Display Only - Cascades from TCR |
Provider Information |
Follow-up Center Code |
Display Only - Cascades from Database |
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Provider Information |
Follow-up Center Code |
Display Only - Cascades from Database |
Provider Information |
Follow-up Center Type |
Display Only - Cascades from Database |
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Provider Information |
Follow-up Center Type |
Display Only - Cascades from Database |
Provider Information |
Physician Name |
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Provider Information |
Physician Name |
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Provider Information |
NPI# |
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Provider Information |
NPI# |
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Provider Information |
Follow-up Care Provided By |
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Provider Information |
Follow-up Care Provided By |
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Provider Information |
Follow-up Care Provided By//Specify |
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Provider Information |
Follow-up Care Provided By//Specify |
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Donor Information |
UNOS Donor ID # |
Display Only - Cascades from Database |
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Donor Information |
UNOS Donor ID # |
Display Only - Cascades from Database |
Donor Information |
Donor Type |
Display Only - Cascades from Database |
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Donor Information |
Donor Type |
Display Only - Cascades from Database |
Donor Information |
OPO |
Display Only - Cascades from feedback |
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Donor Information |
OPO |
Display Only - Cascades from feedback |
Patient Status at Time of Follow-up |
Date: Last Seen, Retransplanted or Death |
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Patient Status at Time of Follow-up |
Date: Last Seen, Retransplanted or Death |
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Patient Status at Time of Follow-up |
Patient Status |
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Patient Status at Time of Follow-up |
Patient Status |
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Patient Status at Time of Follow-up |
Primary Cause of Death |
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Patient Status at Time of Follow-up |
Primary Cause of Death |
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Patient Status at Time of Follow-up |
Primary Cause of Death//Specify |
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Patient Status at Time of Follow-up |
Primary Cause of Death//Specify |
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Patient Status at Time of Follow-up |
Contributory Cause of Death |
Not required |
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Patient Status at Time of Follow-up |
Contributory Cause of Death |
Not required |
Patient Status at Time of Follow-up |
Contributory Cause of Death//Specify |
Not required |
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Patient Status at Time of Follow-up |
Contributory Cause of Death//Specify |
Not required |
Patient Status at Time of Follow-up |
Contributory Cause of Death |
Not required |
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Patient Status at Time of Follow-up |
Contributory Cause of Death |
Not required |
Patient Status at Time of Follow-up |
Contributory Cause of Death//Specify |
Not required |
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Patient Status at Time of Follow-up |
Contributory Cause of Death//Specify |
Not required |
Patient Status at Time of Follow-up |
Has the patient been hospitalized since the last patient status date |
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Patient Status at Time of Follow-up |
Has the patient been hospitalized since the last patient status date |
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Patient Status at Time of Follow-up |
Disease Recurrence |
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Patient Status at Time of Follow-up |
Disease Recurrence |
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Patient Status at Time of Follow-up |
Disease Recurrence |
Display Only - Cascades from Database |
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Patient Status at Time of Follow-up |
Disease Recurrence |
Display Only - Cascades from Database |
Clinical Information |
Confirmed Biopsy from Previous Follow- up |
Display Only - Cascades from Database |
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Clinical Information |
Confirmed Biopsy from Previous Follow-up |
Display Only - Cascades from Database |
Patient Status at Time of Follow-up |
Functional Status |
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Patient Status at Time of Follow-up |
Functional Status |
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Patient Status at Time of Follow-up |
Working for income |
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Patient Status at Time of Follow-up |
Cognitive Development |
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Patient Status at Time of Follow-up |
Primary Insurance at Follow-up |
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Patient Status at Time of Follow-up |
Motor Development |
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Patient Status at Time of Follow-up |
Primary Source of Payment, Specify |
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Patient Status at Time of Follow-up |
Working for income |
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Clinical Information |
HIV Serology |
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Patient Status at Time of Follow-up |
Academic Progress |
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Clinical Information |
HIV NAT |
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Patient Status at Time of Follow-up |
Academic Activity Level |
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Clinical Information |
HbsAg |
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Patient Status at Time of Follow-up |
Primary Insurance at Follow-up |
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Clinical Information |
HBV DNA |
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Patient Status at Time of Follow-up |
Primary Source of Payment, Specify |
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Clinical Information |
HBV Core Antibody |
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Clinical Information |
Date of Measurement |
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Clinical Information |
HCV Serology |
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Clinical Information |
Height |
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Clinical Information |
HCV NAT |
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Clinical Information |
Height//Status |
Value or status is reported, not both |
Clinical Information |
New diabetes onset between last follow-up to the current follow-up |
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Clinical Information |
Height Percentile |
Calculated for display only |
Clinical Information |
If yes, insulin dependent |
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Clinical Information |
Weight |
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Clinical Information |
Graft Status |
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Clinical Information |
Weight//Status |
Value or status is reported, not both |
Clinical Information |
If Functioning, Most Recent Serum Creatinine |
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Clinical Information |
Weight Percentile |
Calculated for display only |
Clinical Information |
If Functioning, Most Recent Serum Creatinine//Status |
Value or status is reported, not both |
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Clinical Information |
BMI |
Display Only - Cascades from Database |
Clinical Information |
Date of Graft Failure: |
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Clinical Information |
BMI |
Calculated for display only |
Clinical Information |
Primary Cause of Graft Failure: |
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Clinical Information |
HIV Serology |
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Clinical Information |
Primary Cause of Graft Failure//Other, Specify: |
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Clinical Information |
HIV NAT |
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Clinical Information |
Dialysis Since Last Follow-up |
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Clinical Information |
HbsAg |
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Clinical Information |
Date Maintenance Dialysis Resumed |
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Clinical Information |
HBV DNA |
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Clinical Information |
Did patient have any acute rejection episodes during the follow-up period |
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Clinical Information |
HBV Core Antibody |
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Clinical Information |
CMV IgG |
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Clinical Information |
HCV Serology |
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Clinical Information |
CMV IgM |
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Clinical Information |
HCV NAT |
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Clinical Information |
Post Transplant Malignancy |
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Clinical Information |
New diabetes onset between last follow-up to the current follow-up |
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Clinical Information |
Donor Related |
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Clinical Information |
If yes, insulin dependent |
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Clinical Information |
Recurrence of Pre-Tx Tumor |
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Clinical Information |
Graft Status |
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Clinical Information |
Post Tx De Novo Solid Tumor |
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Clinical Information |
Date of Graft Failure: |
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Clinical Information |
De Novo Lymphoproliferative disease and Lymphoma |
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Clinical Information |
Primary Cause of Graft Failure: |
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Immunosuppressive Information |
Were any medications given during the follow-up period for maintenance |
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Clinical Information |
Primary Cause of Graft Failure//Other, Specify: |
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Immunosuppressive Information |
Previous Validated Maintenance Follow-up Medications |
Display Only - Cascades from Database |
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Clinical Information |
Dialysis Since Last Follow-up |
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Immunosuppressive Information |
Immunosuppression medication |
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Clinical Information |
Date Maintenance Dialysis Resumed |
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Immunosuppressive Information |
Immunosuppression medication indication |
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Clinical Information |
Did patient have any acute rejection episodes during the follow-up period |
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Clinical Information |
Is growth hormone therapy used during this follow-up period |
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Clinical Information |
Post Transplant Malignancy |
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Clinical Information |
Donor Related |
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PUBLIC BURDEN STATEMENT: |
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Clinical Information |
Recurrence of Pre-Tx Tumor |
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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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Clinical Information |
Post Tx De Novo Solid Tumor |
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Clinical Information |
De Novo Lymphoproliferative disease and Lymphoma |
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Clinical Information |
Fracture in the past year (or since last follow-up) |
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Clinical Information |
Specify Location and number of fractures |
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Clinical Information |
Spine-compression fracture |
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Clinical Information |
Specify Location and number of fractures |
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Clinical Information |
Extremity |
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Clinical Information |
Specify Location and number of fractures |
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Clinical Information |
Other |
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Clinical Information |
AVN (avascular necrosis) |
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Immunosuppressive Information |
Were any medications given during the follow-up period for maintenance |
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Immunosuppressive Information |
Previous Validated Maintenance Follow-up Medications |
Display Only - Cascades from Database |
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Immunosuppressive Information |
Immunosuppression medication |
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Immunosuppressive Information |
Immunosuppression medication indication |
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PUBLIC BURDEN STATEMENT: |
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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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