40 Pancreas Transplant Candidate Registration_Form_clean.xl

TCR - Pancreas - Adult				TCR - Pancreas - 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	SSN:	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	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	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	Academic Progress:
Patient Status	Previous Transplant//Graft Fail Date	Display Only - Cascades from Database		Patient Status	Academic Activity Level:
Patient Status	Previous Pancreas Islet Infusion:			Patient Status	Previous Transplant//Organ	Display Only - Cascades from Database
Source of Payment	Source of Payment//Primary:			Patient Status	Previous Transplant//Date	Display Only - Cascades from Database
Source of Payment	Foreign Government//Specify:	Display Only		Patient Status	Previous Transplant//Graft Fail Date	Display Only - Cascades from Database
Clinical Information	Height in cm://Height:			Source of Payment	Source of Payment//Primary:
Clinical Information	Height Status//ST=	Value or status is reported, not both		Source of Payment	Foreign Government//Specify:
Clinical Information	Height Growth percentiles//%ile	Calculated for display only		Clinical Information	Height Measurement Date
Clinical Information	Weight in kg://Weight:			Clinical Information	Height in cm://Height:
Clinical Information	Weight Status//ST=	Value or status is reported, not both		Clinical Information	Height Status//ST=	Value or status is reported, not both
Clinical Information	Weight Growth percentiles//%ile	Calculated for display only		Clinical Information	Height Growth percentiles//%ile	Calculated for display only
Clinical Information	BMI:	Display Only - Cascades from Database		Clinical Information	Weight Measurement Date
Clinical Information	BMI://%ile	Calculated for display only		Clinical Information	Weight in kg://Weight:
Clinical Information	ABO Blood Group:			Clinical Information	Weight Status//ST=	Value or status is reported, not both
Clinical Information	Primary Diagnosis:			Clinical Information	Weight Growth percentiles//%ile	Calculated for display only
Clinical Information	Primary Diagnosis//Specify:			Clinical Information	BMI:	Display Only - Cascades from Database
General Medical Factors	Diabetes:			Clinical Information	BMI://%ile	Calculated for display only
General Medical Factors	Patient on insulin?			Clinical Information	ABO Blood Group:	Display Only - Cascades from Waitlist
General Medical Factors	If on insulin, enter the insulin date			Clinical Information	Primary Diagnosis:
General Medical Factors	If on insulin, enter the insulin date//ST=	Value or status is reported, not both		Clinical Information	Primary Diagnosis//Specify:
General Medical Factors	Total insulin dosage units			General Medical Factors	Diabetes:
General Medical Factors	Total insulin dosage units//ST=	Value or status is reported, not both		General Medical Factors	Patient on insulin?
General Medical Factors	Insulin duration of use:			General Medical Factors	If on insulin, enter the insulin date
General Medical Factors	Insulin duration of use://ST=	Value or status is reported, not both		General Medical Factors	If on insulin, enter the insulin date//ST=	Value or status is reported, not both
General Medical Factors	Symptomatic Peripheral Vascular Disease:			General Medical Factors	Total insulin dosage units
General Medical Factors	Drug Treated COPD:			General Medical Factors	Total insulin dosage units//ST=	Value or status is reported, not both
General Medical Factors	Any previous Malignancy:			General Medical Factors	Insulin duration of use:
General Medical Factors	Any previous Malignancy//Specify Type:			General Medical Factors	Insulin duration of use://ST=	Value or status is reported, not both
General Medical Factors	Any previous Malignancy//Specify:			General Medical Factors	Any previous Malignancy:
General Medical Factors	Total Serum Albumin:			General Medical Factors	Any previous Malignancy//Specify Type:
General Medical Factors	Total Serum Albumin//ST=	Value or status is reported, not both		General Medical Factors	Any previous Malignancy//Specify:
General Medical Factors	C-Peptide Value			General Medical Factors	Total Serum Albumin:
General Medical Factors	C-Peptide Value://ST=	Value or status is reported, not both		General Medical Factors	Total Serum Albumin//ST=	Value or status is reported, not both
General Medical Factors	Hba1c (%):			General Medical Factors	C-Peptide Value
General Medical Factors	Hba1c (%)://ST	Value or status is reported, not both		General Medical Factors	C-Peptide Value://ST=	Value or status is reported, not both
Pancreas Medical Factors	Age of Diabetes Onset:			General Medical Factors	Hba1c (%):
Pancreas Medical Factors	Age of Diabetes Onset//ST=	Value or status is reported, not both		General Medical Factors	Hba1c (%)://ST	Value or status is reported, not both
				Pancreas Medical Factors	Age of Diabetes Onset:
				Pancreas Medical Factors	Age of Diabetes Onset//ST=	Value or status is reported, not both
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.
				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.