| TCR - Heart - Adult |
|
TCR - Heart - Pediatric |
| Fields to be completed by members |
Fields to be completed by members |
|
|
|
|
|
|
|
| Form Section |
Field Label |
Notes |
|
Form Section |
Field Label |
Notes |
| Provider Information |
Transplant Center Code |
Display Only - Cascades from Waitlist |
|
Provider Information |
Transplant Center Code |
Display Only - Cascades from Waitlist |
| Provider Information |
Transplant Center Type://Recipient Center |
Display Only - Cascades from Waitlist |
|
Provider Information |
Transplant Center Type://Recipient Center |
Display Only - Cascades from Waitlist |
| Candidate Information |
Organ Registered: |
Display Only - Cascades from Waitlist |
|
Candidate Information |
Organ Registered: |
Display Only - Cascades from Waitlist |
| Candidate Information |
Date of Listing or Add: |
Display Only - Cascades from Waitlist |
|
Candidate Information |
Date of Listing or Add: |
Display Only - Cascades from Waitlist |
| Candidate Information |
Last Name: |
Cascades from Waitlist |
|
Candidate Information |
Last Name: |
Cascades from Waitlist |
| Candidate Information |
First Name: |
Cascades from Waitlist |
|
Candidate Information |
First Name: |
Cascades from Waitlist |
| Candidate Information |
Middle Initial://MI: |
Not required |
|
Candidate Information |
Middle Initial://MI: |
Not required |
| Candidate Information |
Previous Surname: |
Not required |
|
Candidate Information |
Previous Surname: |
Not required |
| Candidate Information |
SSN: |
Display Only - Cascades from Waitlist |
|
Candidate Information |
SSN: |
Display Only - Cascades from Waitlist |
| Candidate Information |
Gender: |
Cascades from Waitlist |
|
Candidate Information |
Gender: |
Cascades from Waitlist |
| Candidate Information |
HIC: |
Not required |
|
Candidate Information |
HIC: |
Not required |
| Candidate Information |
Date of Birth://DOB: |
Cascades from Waitlist |
|
Candidate Information |
Date of Birth://DOB: |
Cascades from Waitlist |
| Candidate Information |
State of Permanent Residence: |
Cascades from Waitlist |
|
Candidate Information |
State of Permanent Residence: |
Cascades from Waitlist |
| Candidate Information |
Permanent ZIP Code: |
Cascades from Waitlist |
|
Candidate Information |
Permanent ZIP Code: |
Cascades from Waitlist |
| Candidate Information |
Ethnicity: |
Cascades from Waitlist |
|
Candidate Information |
Ethnicity: |
Cascades from Waitlist |
| Candidate Information |
Race: |
Cascades from Waitlist |
|
Candidate Information |
Race: |
Cascades from Waitlist |
| Candidate Information |
Citizenship: |
|
|
Candidate Information |
Citizenship: |
|
| Candidate Information |
Year of Entry to the U.S. |
|
|
Candidate Information |
Year of Entry to the U.S. |
|
| Candidate Information |
Year of Entry to the U.S Status//ST= |
Value or status is reported, not both |
|
Candidate Information |
Year of Entry to the U.S Status//ST= |
Value or status is reported, not both |
| Candidate Information |
Country of Permanent Residence |
|
|
Candidate Information |
Country of Permanent Residence |
|
| Candidate Information |
Highest Education Level: |
|
|
Candidate Information |
Highest Education Level: |
|
| Patient Status |
Patient on Life Support: |
|
|
Patient Status |
Patient on Life Support: |
|
| Patient Status |
Life Support://Extra Corporeal Membrane Oxygenation |
|
|
Patient Status |
Life Support://Extra Corporeal Membrane Oxygenation |
|
| Patient Status |
Life Support://Intra Aortic Balloon Pump |
|
|
Patient Status |
Life Support://Intra Aortic Balloon Pump |
|
| Patient Status |
Life Support://Prostaglandins |
|
|
Patient Status |
Life Support://Prostaglandins |
|
| Patient Status |
Life Support://Intravenous Inotropes |
|
|
Patient Status |
Life Support://Intravenous Inotropes |
|
| Patient Status |
Life Support://Inhaled NO |
|
|
Patient Status |
Life Support://Inhaled NO |
|
| Patient Status |
Life Support://Ventilator |
|
|
Patient Status |
Life Support://Ventilator |
|
| Patient Status |
Life Support://Other Mechanism, Specify |
|
|
Patient Status |
Life Support://Other Mechanism, Specify |
|
| Patient Status |
Life Support: Other Mechanism//Specify: |
|
|
Patient Status |
Life Support: Other Mechanism//Specify: |
|
| Patient Status |
Life Support://Patient on Ventricular Assist Device: |
|
|
Patient Status |
Life Support://Patient on Ventricular Assist Device: |
|
| Patient Status |
Life Support://VAD Brand1: |
|
|
Patient Status |
Life Support://VAD Brand1: |
|
| Patient Status |
Life Support://VAD Brand2: |
|
|
Patient Status |
Life Support://VAD Brand2: |
|
| Patient Status |
Life Support:VAD Brand1//Specify: |
|
|
Patient Status |
Life Support:VAD Brand1//Specify: |
|
| Patient Status |
Life Support:VAD Brand2//Specify: |
|
|
Patient Status |
Life Support:VAD Brand2//Specify: |
|
| Patient Status |
Functional Status: |
|
|
Patient Status |
Functional Status: |
|
| Patient Status |
Working for income: |
|
|
Patient Status |
Cognitive Development: |
|
| Patient Status |
Previous Transplant//Organ |
Display Only - Cascades from Database |
|
Patient Status |
Motor Development: |
|
| Patient Status |
Previous Transplant//Date |
Display Only - Cascades from Database |
|
Patient Status |
Working for income: |
|
| Patient Status |
Previous Transplant//Graft Fail Date |
Display Only - Cascades from Database |
|
Patient Status |
Academic Progress: |
|
| Source of Payment |
Source of Payment//Primary: |
|
|
Patient Status |
Academic Activity Level: |
|
| Source of Payment |
Foreign Government//Specify: |
|
|
Patient Status |
Previous Transplant//Organ |
Display Only - Cascades from Database |
| Clinical Information |
Height in cm://Height: |
|
|
Patient Status |
Previous Transplant//Date |
Display Only - Cascades from Database |
| Clinical Information |
Height Status//ST= |
Value or status is reported, not both |
|
Patient Status |
Previous Transplant//Graft Fail Date |
Display Only - Cascades from Database |
| Clinical Information |
Height Growth percentiles//%ile |
Calculated for display only |
|
Source of Payment |
Source of Payment//Primary: |
|
| Clinical Information |
Weight in kg://Weight: |
|
|
Source of Payment |
Foreign Government//Specify: |
|
| Clinical Information |
Weight Status//ST= |
Value or status is reported, not both |
|
Clinical Information |
Height Measurement Date |
|
| Clinical Information |
Weight Growth percentiles//%ile |
Calculated for display only |
|
Clinical Information |
Height in cm://Height: |
|
| Clinical Information |
BMI: |
Display Only - Cascades from Database |
|
Clinical Information |
Height Status//ST= |
Value or status is reported, not both |
| Clinical Information |
BMI://%ile |
Calculated for display only |
|
Clinical Information |
Height Growth percentiles//%ile |
Calculated for display only |
| Clinical Information |
ABO Blood Group: |
Display Only - Cascades from Waitlist |
|
Clinical Information |
Weight Measurement Date |
|
| Clinical Information |
Primary Diagnosis: |
|
|
Clinical Information |
Weight in kg://Weight: |
|
| Clinical Information |
Primary Diagnosis//Specify: |
|
|
Clinical Information |
Weight Status//ST= |
Value or status is reported, not both |
| General Medical Factors |
Diabetes: |
|
|
Clinical Information |
Weight Growth percentiles//%ile |
Calculated for display only |
| General Medical Factors |
Dialysis: |
|
|
Clinical Information |
BMI: |
Display Only - Cascades from Database |
| General Medical Factors |
Symptomatic Cerebrovascular Disease: |
|
|
Clinical Information |
BMI://%ile |
Calculated for display only |
| General Medical Factors |
Any previous Malignancy: |
|
|
Clinical Information |
ABO Blood Group: |
Display Only - Cascades for Waitlist |
| General Medical Factors |
Any previous Malignancy//Specify Type: |
|
|
Clinical Information |
Primary Diagnosis: |
|
| General Medical Factors |
Any previous Malignancy//Specify: |
|
|
Clinical Information |
Primary Diagnosis//Specify: |
|
| General Medical Factors |
Most Recent Serum Creatinine: |
|
|
General Medical Factors |
Diabetes: |
|
| General Medical Factors |
Most Recent Serum Creatinine//ST= |
Value or status is reported, not both |
|
General Medical Factors |
Dialysis: |
|
| Heart Medical Factors |
Implantable Defibrillator: |
|
|
General Medical Factors |
Symptomatic Cerebrovascular Disease: |
|
| Heart Medical Factors |
Exercise Oxygen Consumption: |
|
|
General Medical Factors |
Any previous Malignancy: |
|
| Heart Medical Factors |
Exercise Oxygen Consumption//ST= |
Value or status is reported, not both |
|
General Medical Factors |
Any previous Malignancy//Specify Type: |
|
| Heart Medical Factors |
PA (sys) mm/Hg: |
|
|
General Medical Factors |
Any previous Malignancy//Specify: |
|
| Heart Medical Factors |
PA (sys) mm/Hg//ST= |
Value or status is reported, not both |
|
General Medical Factors |
Most Recent Serum Creatinine: |
|
| Heart Medical Factors |
PA (sys) mm/Hg Inotropes/Vasodilators |
|
|
General Medical Factors |
Most Recent Serum Creatinine//ST= |
Value or status is reported, not both |
| Heart Medical Factors |
PA (dia) mm/Hg: |
|
|
General Medical Factors |
Total Serum Albumin: |
|
| Heart Medical Factors |
PA (dia) mm/Hg//ST= |
Value or status is reported, not both |
|
General Medical Factors |
Total Serum Albumin//ST= |
Value or status is reported, not both |
| Heart Medical Factors |
PA (dia) mm/Hg Inotropes/Vasodilators |
|
|
Heart Medical Factors |
Sudden Death: |
|
| Heart Medical Factors |
PA (mean) mm/Hg: |
|
|
Heart Medical Factors |
Implantable Defibrillator: |
|
| Heart Medical Factors |
PA (mean) mm/Hg//ST= |
Value or status is reported, not both |
|
Heart Medical Factors |
Exercise Oxygen Consumption: |
|
| Heart Medical Factors |
PA (mean) mm/Hg Inotropes/Vasodilators |
|
|
Heart Medical Factors |
Exercise Oxygen Consumption//ST= |
Value or status is reported, not both |
| Heart Medical Factors |
PCW (mean) mm/Hg: |
|
|
Heart Medical Factors |
PA (sys) mm/Hg: |
|
| Heart Medical Factors |
PCW (mean) mm/Hg//ST= |
Value or status is reported, not both |
|
Heart Medical Factors |
PA (sys) mm/Hg//ST= |
Value or status is reported, not both |
| Heart Medical Factors |
PCW (mean) mm/Hg Inotropes/Vasodilators |
|
|
Heart Medical Factors |
PA (sys) mm/Hg Inotropes/Vasodilators |
|
| Heart Medical Factors |
CO L/min: |
|
|
Heart Medical Factors |
PA (dia) mm/Hg: |
|
| Heart Medical Factors |
CO L/min//ST= |
Value or status is reported, not both |
|
Heart Medical Factors |
PA (dia) mm/Hg//ST= |
Value or status is reported, not both |
| Heart Medical Factors |
CO L/min Inotropes/Vasodilators |
|
|
Heart Medical Factors |
PA (dia) mm/Hg Inotropes/Vasodilators |
|
| Heart Medical Factors |
History of Cigarette Use: |
|
|
Heart Medical Factors |
PA (mean) mm/Hg: |
|
| Heart Medical Condition |
Duration of Abstinence: |
|
|
Heart Medical Factors |
PA (mean) mm/Hg//ST= |
Value or status is reported, not both |
| Heart Medical Condition |
Prior Cardiac Surgery (non-transplant): |
|
|
Heart Medical Factors |
PA (mean) mm/Hg Inotropes/Vasodilators |
|
| Heart Medical Condition |
If yes, check all that apply: |
|
|
Heart Medical Factors |
PCW (mean) mm/Hg: |
|
| Heart Medical Condition |
Prior Cardiac Surgery type//Specify: |
|
|
Heart Medical Factors |
PCW (mean) mm/Hg//ST= |
Value or status is reported, not both |
|
|
|
|
Heart Medical Factors |
PCW (mean) mm/Hg Inotropes/Vasodilators |
|
|
|
|
Heart Medical Factors |
CO L/min: |
|
| PUBLIC BURDEN STATEMENT: |
|
|
|
Heart Medical Factors |
CO L/min//ST= |
Value or status is reported, not both |
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 0.27 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.
|
|
Heart Medical Factors |
CO L/min Inotropes/Vasodilators |
|
|
Heart Medical Factors |
History of Cigarette Use: |
|
|
Windows User:
Heart word is misspelled. UNOS: Corrected.
Heart Medical Condition |
Duration of Abstinence: |
|
|
Heart Medical Condition |
Prior Thoracic Surgery other than prior transplant: |
|
|
Heart Medical Condition |
Prior Thoracic Surgery//If yes, number of prior sternotomies: |
|
|
Heart Medical Condition |
Prior Thoracic Surgery//If yes, number of prior thoracotomies: |
|
|
Heart Medical Condition |
Prior Thoracic Surgery//Prior congenital cardiac surgery: |
|
|
Heart Medical Condition |
Prior congenital cardiac surgery//If yes, palliative surgery: |
|
|
Heart Medical Condition |
Prior congenital cardiac surgery//If yes, corrective surgery: |
|
|
Heart Medical Condition |
Prior congenital cardiac surgery//If yes, single ventricular physiology: |
|
|
|
|
|
|
|
|
|
|
|
|
|
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 0.27 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.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|