TCR - Liver - Adult |
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TCR - Liver - Pediatric |
Fields to be completed by members |
Fields to be completed by members |
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Form Section |
Field Label |
Notes |
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Form Section |
Field Label |
Notes |
Provider Information |
Transplant Center Code |
Display Only - Cascades from Waitlist |
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Provider Information |
Transplant Center Code |
Display Only - Cascades from Waitlist |
Provider Information |
Transplant Center Type://Recipient Center |
Display Only - Cascades from Waitlist |
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Provider Information |
Transplant Center Type://Recipient Center |
Display Only - Cascades from Waitlist |
Candidate Information |
Organ Registered: |
Display Only - Cascades from Waitlist |
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Candidate Information |
Organ Registered: |
Display Only - Cascades from Waitlist |
Candidate Information |
Date of Listing or Add: |
Display Only - Cascades from Waitlist |
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Candidate Information |
Date of Listing or Add: |
Display Only - Cascades from Waitlist |
Candidate Information |
Last Name: |
Cascades from Waitlist |
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Candidate Information |
Last Name: |
Cascades from Waitlist |
Candidate Information |
First Name: |
Cascades from Waitlist |
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Candidate Information |
First Name: |
Cascades from Waitlist |
Candidate Information |
Middle Initial://MI: |
Not required |
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Candidate Information |
Middle Initial://MI: |
Not required |
Candidate Information |
Previous Surname: |
Not required |
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Candidate Information |
Previous Surname: |
Not required |
Candidate Information |
SSN: |
Display Only - Cascades from Waitlist |
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Candidate Information |
SSN: |
Display Only - Cascades from Waitlist |
Candidate Information |
Gender: |
Cascades from Waitlist |
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Candidate Information |
Gender: |
Cascades from Waitlist |
Candidate Information |
HIC: |
Not required |
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Candidate Information |
HIC: |
Not required |
Candidate Information |
Date of Birth://DOB: |
Cascades from Waitlist |
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Candidate Information |
Date of Birth://DOB: |
Cascades from Waitlist |
Candidate Information |
State of Permanent Residence: |
Cascades from Waitlist |
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Candidate Information |
State of Permanent Residence: |
Cascades from Waitlist |
Candidate Information |
Permanent ZIP Code: |
Cascades from Waitlist |
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Candidate Information |
Permanent ZIP Code: |
Cascades from Waitlist |
Candidate Information |
Ethnicity: |
Cascades from Waitlist |
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Candidate Information |
Ethnicity: |
Cascades from Waitlist |
Candidate Information |
Select all origins that apply: |
Cascades from Waitlist |
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Candidate Information |
Select all origins that apply: |
Cascades from Waitlist |
Candidate Information |
Ethnicity/Race: |
Cascades from Waitlist |
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Candidate Information |
Ethnicity/Race: |
Cascades from Waitlist |
Candidate Information |
Citizenship: |
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Candidate Information |
Citizenship: |
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Candidate Information |
Year of Entry to the U.S. |
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Candidate Information |
Year of Entry to the U.S. |
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Candidate Information |
Year of Entry to the U.S Status//ST= |
Value or status is reported, not both |
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Candidate Information |
Year of Entry to the U.S Status//ST= |
Value or status is reported, not both |
Candidate Information |
Country of Permanent Residence |
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Candidate Information |
Country of Permanent Residence |
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Candidate Information |
Highest Education Level: |
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Candidate Information |
Highest Education Level: |
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Patient Status |
Patient on Life Support: |
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Patient Status |
Patient on Life Support: |
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Patient Status |
Life Support://Ventilator |
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Patient Status |
Life Support://Ventilator |
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Patient Status |
Life Support://Artifical Liver |
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Patient Status |
Life Support://Artifical Liver |
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Patient Status |
Life Support://Other Mechanism, Specify |
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Patient Status |
Life Support://Other Mechanism, Specify |
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Patient Status |
Life Support:Other Mechanism//Specify: |
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Patient Status |
Life Support:Other Mechanism//Specify: |
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Patient Status |
Functional Status: |
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Patient Status |
Functional Status: |
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Patient Status |
Working for income: |
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Patient Status |
Cognitive Development: |
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Patient Status |
Previous Transplant//Organ |
Display Only - Cascades from Database |
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Patient Status |
Motor Development: |
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Patient Status |
Previous Transplant//Date |
Display Only - Cascades from Database |
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Patient Status |
Academic Progress: |
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Patient Status |
Previous Transplant//Graft Fail Date |
Display Only - Cascades from Database |
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Patient Status |
Academic Activity Level: |
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Patient Status |
Previous Pancreas Islet Infusion: |
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Patient Status |
Previous Transplant//Organ |
Display Only - Cascades from Database |
Source of Payment |
Source of Payment//Primary: |
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Patient Status |
Previous Transplant//Date |
Display Only - Cascades from Database |
Source of Payment |
Foreign Government//Specify: |
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Patient Status |
Previous Transplant//Graft Fail Date |
Display Only - Cascades from Database |
Clinical Information |
Height in cm://Height: |
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Source of Payment |
Source of Payment//Primary: |
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Clinical Information |
Height Status//ST= |
Value or status is reported, not both |
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Source of Payment |
Foreign Government//Specify: |
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Clinical Information |
Height Growth percentiles//%ile |
Calculated for display only |
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Clinical Information |
Date of Measurement: |
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Clinical Information |
Weight in kg://Weight: |
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Clinical Information |
Height Measurement Date |
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Clinical Information |
Weight Status//ST= |
Value or status is reported, not both |
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Clinical Information |
Height in cm://Height: |
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Clinical Information |
Weight Growth percentiles//%ile |
Calculated for display only |
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Clinical Information |
Height Status//ST= |
Value or status is reported, not both |
Clinical Information |
BMI: |
Display Only - Cascades from Database |
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Clinical Information |
Height Growth percentiles//%ile |
Calculated for display only |
Clinical Information |
BMI://%ile |
Calculated for display only |
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Clinical Information |
Weight Measurement Date |
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Clinical Information |
ABO Blood Group: |
Display Only - Cascades from Waitlist |
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Clinical Information |
Weight in kg://Weight: |
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Clinical Information |
Primary Diagnosis: |
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Clinical Information |
Weight Status//ST= |
Value or status is reported, not both |
Clinical Information |
Primary Diagnosis//Specify: |
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Clinical Information |
Weight Growth percentiles//%ile |
Calculated for display only |
Clinical Information |
Secondary Diagnosis: |
Not required |
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Clinical Information |
BMI: |
Display Only - Cascades from Database |
Clinical Information |
Secondary Diagnosis//Specify: |
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Clinical Information |
BMI://%ile |
Calculated for display only |
General Medical Factors |
Diabetes: |
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Clinical Information |
ABO Blood Group: |
Display Only - Cascades from Waitlist |
General Medical Factors |
Any previous Malignancy: |
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Clinical Information |
Primary Diagnosis: |
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General Medical Factors |
Any previous Malignancy//Specify Type: |
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Clinical Information |
Primary Diagnosis//Specify: |
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General Medical Factors |
Cholangiocarcinoma//Neoadjuvant Therapy |
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Clinical Information |
Secondary Diagnosis: |
Not required |
General Medical Factors |
Any previous Malignancy//Specify: |
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Clinical Information |
Secondary Diagnosis//Specify: |
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Clinical Information |
Has the candidate ever had a diagnosis of HCC? |
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General Medical Factors |
Diabetes: |
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Liver Medical Factors |
Previous Upper Abdominal Surgery: |
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General Medical Factors |
Any previous Malignancy: |
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Liver Medical Factors |
Spontaneous Bacterial Peritonitis: |
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General Medical Factors |
Any previous Malignancy//Specify Type: |
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Liver Medical Factors |
History of Portal Vein Thrombosis: |
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General Medical Factors |
Cholangiocarcinoma//Neoadjuvant Therapy |
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Liver Medical Factors |
History of TIPSS: |
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General Medical Factors |
Any previous Malignancy//Specify: |
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General Medical Factors |
Has the candidate ever had a diagnosis of HCC? |
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Liver Medical Factors |
Previous Upper Abdominal Surgery: |
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Liver Medical Factors |
Spontaneous Bacterial Peritonitis: |
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PUBLIC BURDEN STATEMENT: |
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Liver Medical Factors |
History of Portal Vein Thrombosis: |
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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 0.27 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.
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Liver Medical Factors |
History of TIPSS: |
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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 0.27 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.
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