Form 3 Living Donor Registration

Records
Living Donor Registration Worksheet
The revised worksheet sample is for reference purposes only and is pending OMB approval.
B.

Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI application.
Currently in the worksheet, a red asterisk is displayed by fields that are required, independent of what other data may be
B.

provided. Based on data provided through the online TIEDI application, additional fields that are dependent on responses
provided in these required fields may become required as well. However, since those fields are not required in every case,
they are not marked with a red asterisk.

Donor ID:
Provider Information
Recipient Center:

Donor Information
Donor Name:
UNOS Donor ID #:
Address:

Home City:

State:

Zip Code:
-

Home Phone:

Work Phone:

Email:

SSN:

Date of Birth:

Gender:

j Male n
k
l
m
n
j Female
k
l
m

j Single
k
l
m
n
j Married
k
l
m
n
Marital Status at Time of Donation:

j Divorced
k
l
m
n
j Separated
k
l
m
n
j Life Partner
k
l
m
n
j Unknown
k
l
m
n

ABO Blood Group:

j A n
k
l
m
j B n
k
l
m
j A1B n
k
l
m
j A2 n
k
l
m
j O n
k
l
m
n
j AB n
k
l
m
j A1 n
k
l
m
j
k
l
m

A2B

j Biological, blood related Parent
k
l
m
n

j Biological, blood related Child
k
l
m
n
j Biological, blood related Identical Twin
k
l
m
n
j Biological, blood related Full Sibling
k
l
m
n
j Biological, blood related Half Sibling
k
l
m
n
j Biological, blood related Other Relative: SPECIFY
k
l
m
n
Donor Type:

j Non-Biological, Spouse
k
l
m
n
j Non-Biological, Life Partner
k
l
m
n
j Non-Biological, Unrelated: Paired Exchange
k
l
m
n
j Non-Biological, Unrelated: Non-Directed Donation
k
l
m
n
(Anonymous)
j Non-Biological, Living/Deceased Exchange
k
l
m
n
j Non-Biological, Unrelated: Domino
k
l
m
n

j Non-Biological, Other Unrelated Directed Donation:
k
l
m
n
Specify
Specify:

Ethnicity/Race:
(select all origins that apply)
Asian
American Indian or Alaska Native

c American Indian
d
e
f
g
c Eskimo
d
e
f
g
c Aleutian
d
e
f
g
c Alaska Indian
d
e
f
g
c American Indian or Alaska Native: Other
d
e
f
g
c American Indian or Alaska Native: Not
d
e
f
g

Specified/Unknown

Black or African American

c Asian Indian/Indian Subd
e
f
g
Continent
c Chinese
d
e
f
g
c Filipino
d
e
f
g
g Japanese
c
d
e
f
c Korean
d
e
f
g
c Vietnamese
d
e
f
g
c Asian: Other
d
e
f
g
g Asian: Not Specified/Unknown
c
d
e
f
Hispanic/Latino

c African American
d
e
f
g

c Mexican
d
e
f
g

c African (Continental)
d
e
f
g

c Puerto Rican (Mainland)
d
e
f
g

c West Indian
d
e
f
g

c Puerto Rican (Island)
d
e
f
g

g Haitian
c
d
e
f

g Cuban
c
d
e
f

c Black or African American: Other
d
e
f
g

c Hispanic/Latino: Other
d
e
f
g

c Black or African American: Not
d
e
f
g
Specified/Unknown
Native Hawaiian or Other Pacific Islander

c Native Hawaiian
d
e
f
g
g Guamanian or Chamorro
c
d
e
f
c Samoan
d
e
f
g
c Native Hawaiian or Other Pacific Islander:
d
e
f
g

Other

c Native Hawaiian or Other Pacific Islander:
d
e
f
g

Not Specified/Unknown

c Hispanic/Latino: Not
d
e
f
g
Specified/Unknown
White

c European Descent
d
e
f
g
c Arab or Middle Eastern
d
e
f
g
g North African (non-Black)
c
d
e
f
c White: Other
d
e
f
g
c White: Not
d
e
f
g
Specified/Unknown

j U.S. CITIZEN
k
l
m
n
Citizenship:

j RESIDENT ALIEN
k
l
m
n
j NON-RESIDENT ALIEN, Year Entered US
k
l
m
n

Year of Entry into U.S.:

j NONE
k
l
m
n
j GRADE SCHOOL (0-8)
k
l
m
n
j HIGH SCHOOL (9-12)
k
l
m
n
Highest Education Level:

j ATTENDED COLLEGE/TECHNICAL SCHOOL
k
l
m
n
j ASSOCIATE/BACHELOR DEGREE
k
l
m
n
j POST-COLLEGE GRADUATE DEGREE
k
l
m
n
j N/A (< 5 YRS OLD)
k
l
m
n
j UNKNOWN
k
l
m
n

Did the donor have health insurance:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

Functional Status:

j No Limitations
k
l
m
n

j Limited Mobility
k
l
m
n
Physical Capacity: (check one)

j Wheelchair bound or more limited
k
l
m
n
j Unknown
k
l
m
n

Working for Income:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

j Disability
k
l
m
n
j Insurance Conflict
k
l
m
n
j Inability to Find Work
k
l
m
n
If No, Not Working Due To: (check
one)

j Donor Choice - Homemaker
k
l
m
n
j Donor Choice - Student Full Time/Part Time
k
l
m
n
j Donor Choice - Retired
k
l
m
n
j Donor Choice - Other
k
l
m
n
j Unknown
k
l
m
n
j Working Full Time
k
l
m
n
j Working Part Time due to Disability
k
l
m
n
j Working Part Time due to Insurance Conflict
k
l
m
n
j Working Part Time due to Inability to Find Full Time
k
l
m
n
Work

If Yes:

j Working Part Time due to Donor Choice
k
l
m
n
j Working Part Time Reason Unknown
k
l
m
n
j Working, Part Time vs. Full Time Unknown
k
l
m
n
Pre-Donation Clinical Information
Viral Detection:
Have any of the following viruses ever
been tested for: HIV, CMV, HBV, HCV,
EBV

j YES n
k
l
m
n
j NO
k
l
m
j YES n
k
l
m
n
j NO
k
l
m

HIV
Test

Result

j Positive
k
l
m
n
Screening:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

Confirmation:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n

Was there clinical disease
(ARC, AIDS):

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

j Positive
k
l
m
n
Antibody:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

RNA:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n

j YES n
k
l
m
n
j NO
k
l
m

CMV
Test

Result

j Positive
k
l
m
n
CMV:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n

Was there clinical disease:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

j Positive
k
l
m
n
IgG:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

IgM:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n

j Positive
k
l
m
n
Nucleic Acid Testing:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

Culture:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n

j YES n
k
l
m
n
j NO
k
l
m

HBV
Test
Was there clinical disease:

Result

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
j Positive
k
l
m
n

Liver Histology:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n
j Negative
k
l
m
n

Core Antibody:

j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

Surface Antigen:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n

j Positive
k
l
m
n
HBV DNA:

j Negative
k
l
m
n

j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n
HDV (Delta Virus):

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n

j YES n
k
l
m
n
j NO
k
l
m

HCV
Test
Was there clinical disease:

Result

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
j Positive
k
l
m
n

Liver Histology:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

Antibody:

j Negative
k
l
m
n

j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n
RIBA:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

HCV RNA:

j Negative
k
l
m
n

j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n

j YES n
k
l
m
n
j NO
k
l
m

EBV
Test
Was there clinical disease:

Result

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

j Positive
k
l
m
n
IgG:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

IgM:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

EBV DNA:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n

Pre-Donation Height and Weight
ST=
Height:

ft

Weight:

lb

in

cm
ST=

j NO
k
l
m
n
j SKIN - SQUAMOUS, BASAL CELL
k
l
m
n
j SKIN - MELANOMA
k
l
m
n
j CNS TUMOR - ASTROCYTOMA
k
l
m
n
j CNS TUMOR - GLIOBLASTOMA
k
l
m
n
MULTIFORME

j CNS TUMOR - MEDULLOBLASTOMA
k
l
m
n
j CNS TUMOR - NEUROBLASTOMA
k
l
m
n
j CNS TUMOR - ANGIOBLASTOMA
k
l
m
n
j CNS TUMOR - MENINGIOMA
k
l
m
n
j CNS TUMOR - OTHER
k
l
m
n
History of Cancer:

j GENITOURINARY - BLADDER
k
l
m
n
j GENITOURINARY - UTERINE CERVIX
k
l
m
n
j GENITOURINARY - UTERINE BODY
k
l
m
n
ENDOMETRIAL

j GENITOURINARY - UTERINE BODY
k
l
m
n
CHORIOCARCINOMA
j GENITOURINARY - VULVA
k
l
m
n
j GENITOURINARY - OVARIAN
k
l
m
n
j GENITOURINARY - PENIS, TESTICULAR
k
l
m
n
j GENITOURINARY - PROSTATE
k
l
m
n
j GENITOURINARY - KIDNEY
k
l
m
n
j GENITOURINARY - UNKNOWN
k
l
m
n

kg

j GASTROINTESTINAL - ESOPHAGEAL
k
l
m
n
j GASTROINTESTINAL - STOMACH
k
l
m
n
j GASTROINTESTINAL - SMALL INTESTINE
k
l
m
n
j GASTROINTESTINAL - COLO-RECTAL
k
l
m
n
j GASTROINTESTINAL - LIVER & BILIARY
k
l
m
n
TRACT

j GASTROINTESTINAL - PANCREAS
k
l
m
n
j BREAST
k
l
m
n
j THYROID
k
l
m
n
j TONGUE/THROAT
k
l
m
n
j LARYNX
k
l
m
n
j LUNG (include broncial)
k
l
m
n
j LEUKEMIA/LYMPHOMA
k
l
m
n
j UNKNOWN
k
l
m
n
j OTHER, SPECIFY
k
l
m
n
Specify:
Cancer Free
Interval:

History of Cigarette Use:

ST=
years

j YES n
k
l
m
n
j NO
k
l
m
j 0-10
k
l
m
n
j 11-20
k
l
m
n
j 21-30
k
l
m
n

If Yes, Check # pack years:

j 31-40
k
l
m
n
j 41-50
k
l
m
n
j >50
k
l
m
n
j Unknown pack years
k
l
m
n

j 0-2 months
k
l
m
n
j 3-12 months
k
l
m
n
j 13-24 months
k
l
m
n
j 25-36 months
k
l
m
n
Duration of Abstinence:

j 37-48 months
k
l
m
n
j 49-60 months
k
l
m
n
j >60 months
k
l
m
n
j Continues To Smoke
k
l
m
n
j Unknown duration
k
l
m
n

Other Tobacco Used:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

Diabetes:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

c Insulin
d
e
f
g
Treatment:

c Oral Hypoglycemic Agent
d
e
f
g
c Diet
d
e
f
g

Pre-Donation Liver Clinical Information
Total Bilirubin:

mg/dl

SGOT/AST:

U/L

SGPT/ALT:

U/L

Alkaline Phosphatase:

units/L

Serum Albumin:

g/dl

Serum Creatinine:

mg/dl

ST=

ST=

ST=

ST=

ST=

ST=
ST=

ST=

INR:

Liver Biopsy:

j YES n
k
l
m
n
j NO
k
l
m

% Macro vesicular fat:

%

% Micro vesicular fat:

%

ST=

ST=

Pre-Donation Kidney Clinical Information

j NO
k
l
m
n
j YES, 0-5 YEARS
k
l
m
n
History of Hypertension:

j YES, 6-10 YEARS
k
l
m
n
j YES, >10 YEARS
k
l
m
n
j YES, UNKNOWN DURATION
k
l
m
n
j UNKNOWN
k
l
m
n

If Yes, Method of Control:
Diet:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Diuretics:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Other Hypertensive Medication:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

Serum Creatinine:

mg/dl

Preoperative Blood Pressure Systolic:

mm/Hg

Preoperative Blood Pressure Diastolic:

mm/Hg

Urinalysis:

j Positive
k
l
m
n

ST=

ST=

ST=

j Negative
k
l
m
n
j Not Done
k
l
m
n

Urine Protein:

j Unknown
k
l
m
n
or
Protein-Creatinine Ratio:

j YES n
k
l
m
n
j NO
k
l
m

Kidney Biopsy:

j 0-5
k
l
m
n
j 6-10
k
l
m
n
j 11-15
k
l
m
n

Glomerulosclerosis:

j 16-20
k
l
m
n
j 20+
k
l
m
n
j Indeterminate
k
l
m
n
Pre-Donation Lung Clinical Information
Before
Bronchodilators
FVC %
predicted:

FEV1 %
predicted:

FEF (25-75%)
% predicted:

TLC %
predicted:

Diffusing lung

After
Bronchodilators
ST=

ST=

ST=

ST=

ST=

ST=

ST=

ST=

capacity
corrected for
alveolar
volume %
predicted:

PaO2 on room
air:

ST=

ST=
mm/Hg

Liver Surgical Information

j Left Lateral Segment (Peds)
k
l
m
n
Type of Transplant Graft:

j Left Lobe
k
l
m
n
j Right Lobe
k
l
m
n
j Domino Whole Liver
k
l
m
n

Kidney Surgical Information

j LEFT KIDNEY
k
l
m
n
j RIGHT KIDNEY
k
l
m
n
Type of Transplant Graft:

j EN-BLOC
k
l
m
n
j Sequential Kidney
k
l
m
n
j HEMI-RENAL
k
l
m
n
j Transabdominal
k
l
m
n

Intended Procedure Type:

j Flank(retroperitoneal)
k
l
m
n
j Laparoscopic Not Hand-assisted
k
l
m
n
j Laparoscopic Hand-assisted
k
l
m
n

Conversion from Laparoscopic to
Open:

j YES n
k
l
m
n
j NO
k
l
m

Lung Surgical Information

Type of Transplant Graft:

j LOBE, RIGHT
k
l
m
n
j LOBE, LEFT
k
l
m
n

Procedure Type:

j Open
k
l
m
n
j Video Assisted Thoracoscopic
k
l
m
n

Conversion from Thoracoscopic to
Open:

j YES n
k
l
m
n
j NO
k
l
m

Intra-operative Complications:

j YES n
k
l
m
n
j NO
k
l
m
c Sacrifice of Second Lobe Specify
d
e
f
g
c Anesthetic Complication Specify
d
e
f
g
c Arrhythmia Requiring Therapy
d
e
f
g

If Yes, Specify:

c Cerebrovasular Accident
d
e
f
g
c Phrenic Nerve Injury
d
e
f
g
c Brachial Plexus Injury
d
e
f
g
c Breast Implant Rupture
d
e
f
g
c Other Specify
d
e
f
g
j RML
k
l
m
n

Sacrifice of Second Lobe,
Specify:

j RUL
k
l
m
n
j LUL
k
l
m
n
j Lingular
k
l
m
n

Anesthetic Complication
Specify:

Arrhythmia requiring therapy:

j Medical therapy
k
l
m
n

j Cardioversion
k
l
m
n
Other Specify:

Post-Operative Information
Date of Initial Discharge:
Donor Status:

Date Last Seen or Death:

j Dead
k
l
m
j Alive n
k
l
m
n

Cause of Death:
Other Specify:

Non-Autologous Blood Administration:

j YES n
k
l
m
n
j NO
k
l
m
PRBC

If Yes, Number of Units:

Platelets
FFP

Liver Related Post-Operative Complications (In first 6 weeks post-donation)
Biliary Complications:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
c Grade 1 b Bilious JP drainage more than 10 days
d
e
f
g

If Yes, Specify:

c Grade 2 b Interventional procedure (ERCP, PTC,
d
e
f
g
percutaneous drainage, etc.)

c Grade 3 b Surgical Intervention
d
e
f
g
Date of surgery:

Vascular Complications Requiring
Intervention:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

c Portal Vein
d
e
f
g
c Hepatic Vein
d
e
f
g
If Yes, Specify:

c Hepatic Artery
d
e
f
g
c Pulmonary Embolus
d
e
f
g
c Deep Vein Thrombosis
d
e
f
g
c Other, Specify
d
e
f
g

Specify:

Other Complications Requiring
Intervention:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
c Renal insufficiency requiring dialysis
d
e
f
g
c Ascites
d
e
f
g

c Line or IV complication
d
e
f
g
c Pneumothorax
d
e
f
g
If Yes, Specify:

c Pneumonia
d
e
f
g
c Wound Complication
d
e
f
g
c Brachial Nerve Injury
d
e
f
g
c Other, specify
d
e
f
g

Specify:

Reoperation:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
c Liver Failure Requiring Transplant Date:
d
e
f
g

If yes, specify reason for reoperation
(during first six weeks):

c Bleeding Complications
d
e
f
g

Date:

c Hernia Repair
d
e
f
g

Date:

c Bowel Obstruction
d
e
f
g

Date:

c Vascular Complications
d
e
f
g

Date:

c Other Specify
d
e
f
g

Date:

Other Specify:

Any Readmission After Initial
Discharge:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
c Wound Infection
d
e
f
g
c Fever
d
e
f
g
c Bowel Obstruction
d
e
f
g

If yes, specify reason for readmission
(during first six weeks):

c Pleural Effusion
d
e
f
g
c Biliary Complications
d
e
f
g
c Vascular Complications
d
e
f
g
c Other, specify
d
e
f
g

Other Specify:
If Yes, Date of First Readmission:

Other Interventional Procedures:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

If Yes, Specify Procedure:
Date of Procedure:

Kidney Related Post-Operative Complications (In first 6 weeks post-donation)
Vascular Complications Requiring
Intervention:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

c Renal Vein
d
e
f
g
c Renal Artery
d
e
f
g
c Aorta
d
e
f
g
If Yes, Specify:

c Vena Cava
d
e
f
g
c Pulmonary Embolus
d
e
f
g
c Deep Vein Thrombosis
d
e
f
g
c Other, specify
d
e
f
g

Specify:

Other Complications Requiring
Intervention:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
c Renal insufficiency requiring dialysis
d
e
f
g
c Ascites
d
e
f
g
c Line or IV complication
d
e
f
g

If Yes, Specify:

c Pneumothorax
d
e
f
g
c Pneumonia
d
e
f
g
c Wound Complication
d
e
f
g
c Brachial Nerve Injury
d
e
f
g
c Other, specify
d
e
f
g

Other Specify:

Reoperation:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

If yes, specify reason for reoperation
(during first six weeks):

c Bleeding
d
e
f
g

Date:

c Hernia Repair
d
e
f
g

Date:

c Bowel Obstruction
d
e
f
g

Date:

c Vascular
d
e
f
g

Date:

c Other Specify
d
e
f
g

Date:

Other Specify:

Any Readmission After Initial
Discharge:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
c Wound Infection
d
e
f
g
c Fever
d
e
f
g

If yes, specify reason for readmission
(during first six weeks):

c Bowel Obstruction
d
e
f
g

c Pleural Effusion
d
e
f
g
c Vascular Complications
d
e
f
g
c Other, specify
d
e
f
g

Other Specify:
If Yes, Date of First Readmission:

Other Interventional Procedures:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

If Yes, Specify Procedure:
Date of Procedure:

Lung Related Post-Operative Complications (In first 6 weeks post-donation)
Post-operative complications during
the initial hospitalization:

j YES n
k
l
m
n
j NO
k
l
m
c Arrhythmia requiring therapy
d
e
f
g
c Bleeding requiring surgical or therapeutic
d
e
f
g
bronchoscopic intervention

c Bowel obstruction or ileus not requiring surgical
d
e
f
g
intervention

c Bowel obstruction or ileus requiring surgical
d
e
f
g
intervention
c Bronchial Stenosis/Stricture not requiring surgical or
d
e
f
g
therapeutic bronchoscopic intervention

c Bronchial Stenosis/Stricture requiring surgical or
d
e
f
g
therapeutic bronchoscopic intervention
c Bronchopleural Fistula requiring surgical or
d
e
f
g
therapeutic bronchoscopic intervention

c Cerebrovascular Accident
d
e
f
g
c Deep Vein Thrombosis
d
e
f
g
c Empyema requiring therapeutic surgical intervention
d
e
f
g
c Epidural-Related Complication
d
e
f
g
c Line or IV Complication
d
e
f
g

If Yes, Specify:

c Loculated pleural effusion requiring surgical
d
e
f
g
intervention
c Pericardial tamponade or pericarditis requiring
d
e
f
g
surgical intervention

c Pericarditis not requiring surgical intervention
d
e
f
g
c Peripheral Nerve Injury
d
e
f
g
c Phrenic Nerve Injury
d
e
f
g
c Placement of Additional Thoracostomy Tube(s),
d
e
f
g
Specify Indication

c Pneumonia/Atelectasis
d
e
f
g
c Prolonged (>14days) Thoracostomy Tube
d
e
f
g
Requirement
c Pulmonary Artery Embolus or Thrombosis
d
e
f
g
c Pulmonary Vein or Left Atrial Thrombosis
d
e
f
g
c Wound Complication
d
e
f
g
c Wound infection requiring surgical intervention
d
e
f
g
c Other Specify
d
e
f
g

j Medical therapy
k
l
m
n
Arrhythmia requiring therapy:

j Cardioversion
k
l
m
n
j Electrophysiologic Ablation
k
l
m
n
j Pneumothorax
k
l
m
n

Placement of Additional
Thoracostomy Tube(s), Indication:

j Pleural effusion
k
l
m
n
j Empyema
k
l
m
n

Other Specify:

Any Readmission After Initial
Discharge:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
c Wound Infection
d
e
f
g
c Fever
d
e
f
g

If yes, specify reason for readmission
(during first six weeks):

c Bowel Obstruction
d
e
f
g
c Pleural Effusion
d
e
f
g

c Vascular Complications
d
e
f
g
c Other, specify
d
e
f
g
Specify:
If Yes, Date of First Readmission:

Post-Operative Clinical Information (Within 6 weeks post-donation)
Most Recent Date of Tests:

ST=
Height:

ft

in

cm
ST=

Weight:

lb

kg

Kidney Post-Operative Clinical Information
Serum Creatinine:

mg/dl

ST=

Post-Op Blood Pressure Systolic:

mm/Hg

Post-Op Blood Pressure Diastolic:

mm/Hg

ST=

ST=

Urinalysis:

j Positive
k
l
m
n
Urine Protein:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j Unknown
k
l
m
n

or
Protein-Creatinine Ratio:

Donor Developed Hypertension
Requiring Medication:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

Liver Post-Operative Clinical Information
Total Bilirubin:

mg/dl

SGOT/AST:

U/L

SGPT/ALT:

U/L

Alkaline Phosphatase:

units/L

Serum Albumin:

g/dl

Serum Creatinine:

mg/dl

INR:

Organ Recovery

ST=

ST=

ST=

ST=

ST=

ST=

ST=

Organ Recovery Date:
Did organ recovery and transplant
occur at the same center?
Organ(s) Recovered
Donor Recovery Facility:
Donor Workup Facility:

j Yes n
k
l
m
n
j No
k
l
m

Recipient Name (Last, First)

Recipient SSN#