Form 4 Living Donor Follow-up

Records
Living Donor Follow-Up 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 provided. Based on data provided
B.

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:
Followup Center:

Donor Information
Name:

DOB:

Transplant Date:
SSN:

Gender:

Donor ID:

Recovery Date:

Organ:

Donor Status
Date of Initial Discharge:

j Living: Donor seen at transplant center
k
l
m
n
j Living: Donor status update by phone or email
k
l
m
n
correspondence between transplant center and donor
j Living: Donor status update by other health care facility
k
l
m
n
j Living; Donor status update via other source (example;
k
l
m
n
recipient)
Most Recent Donor Status since
[mm/dd/yyyy]:

j Living: Donor contacted, declined follow-up with transplant
k
l
m
n
center

j Dead
k
l
m
n
j Lost: No attempt to contact donor
k
l
m
n
j Lost: Unable to contact donor
k
l
m
n

Date: Last Contact or Death
Cause of Death:
Specify:

Functional Status:

j No Limitations
k
l
m
n
Physical Capacity:

j Limited Mobility
k
l
m
n

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:

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

If Yes:

j Working Part Time due to Inability to Find Full Time Work
k
l
m
n
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

Clinical Information
ST=
Current Weight:

lb

Were any of the following procedures performed since [mm/dd/yyyy]:

j Not Done
k
l
m
n
CAT Scan:

j Yes, Normal Results
k
l
m
n
j Yes, Specify Results
k
l
m
n
j Unknown
k
l
m
n

Specify:

j Not Done
k
l
m
n
MRI:

j Yes, Normal Results
k
l
m
n

kg

j Yes, Specify Results
k
l
m
n
j Unknown
k
l
m
n
Specify:

j Not Done
k
l
m
n
Ultrasound:

j Yes, Normal Results
k
l
m
n
j Yes, Specify Results
k
l
m
n
j Unknown
k
l
m
n

Specify:

Liver Clinical Information
Most Recent Values Since [mm/dd/yyyy]:
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=

INR:

Kidney Clinical Information
Most Recent Values Since [mm/dd/yyyy]:
Serum Creatinine:

mg/dl

Blood Pressure Systolic:

mm/Hg

Blood Pressure Diastolic:

mm/Hg

Donor Developed Hypertension Requiring
Medication:

Urinalysis:

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

ST=

ST=

ST=

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:

Maintenance Dialysis:

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

If Yes, Date First Dialyzed:

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

Lung Clinical Information

j No change in activity level
k
l
m
n
j Mild decrease in activity level
k
l
m
n
Activity Level:

j Moderate decrease in activity level
k
l
m
n
j Severe decrease in activity level
k
l
m
n
j Increase in activity level
k
l
m
n
j Unknown
k
l
m
n

j Mild
k
l
m
n
Chronic Incisional Pain:

j Moderate
k
l
m
n

j Severe
k
l
m
n
j Unknown
k
l
m
n
Complications
Has the donor been readmitted since
[mm/dd/yyyy]:
If Yes, Date of First Readmission:
Specify Reason for First Readmission:

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

Kidney Complications Since [mm/dd/yyyy]:

If Yes:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
c Added to UNOS TX candidate waiting list
d
e
f
g
c Other, specify
d
e
f
g

Specify:
Liver Complications Since [mm/dd/yyyy]:

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

c Bile Leak
d
e
f
g
c Hepatic Resection
d
e
f
g
If Yes:

c Abscess
d
e
f
g
c Liver Failure
d
e
f
g
c Added to UNOS TX candidate waiting list
d
e
f
g
c Other, specify
d
e
f
g

Specify:
Complications Since [mm/dd/yyyy]:
Specify:

Recipient Information
Name:
Transplant Date:
SSN:

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