7b Heart Candidate Pediatric Registration

Records
Pediatric Heart Transplant Candidate 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.

Provider Information
Recipient Center:

Candidate Information
Date of Listing or
Add:

Organ Registered:

Last Name:

First Name:

MI:

Previous Surname:

SSN:

Gender:

HIC:

DOB:

State of Permanent Residence:
Permanent ZIP Code:
Is Patient waiting in permanent ZIP
code:

-

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

Ethnicity/Race:
(select all origins that apply)

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

Asian

c Asian Indian/Indian Subd
e
f
g
Continent
c Chinese
d
e
f
g
c Filipino
d
e
f
g
c Japanese
d
e
f
g
c Korean
d
e
f
g
c Vietnamese
d
e
f
g
c Asian: Other
d
e
f
g

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

g Asian: Not Specified/Unknown
c
d
e
f
Black or African American

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

c Haitian
d
e
f
g

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
c Guamanian or Chamorro
d
e
f
g
g Samoan
c
d
e
f
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
c North African (non-Black)
d
e
f
g
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 to the 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

j IN INTENSIVE CARE UNIT
k
l
m
n

Medical Condition at time of listing:

j HOSPITALIZED NOT IN ICU
k
l
m
n
j NOT HOSPITALIZED
k
l
m
n

Patient on Life Support:

j YES n
k
l
m
n
j NO
k
l
m
c Extra Corporeal Membrane Oxygenation
d
e
f
g
c Intra Aortic Balloon Pump
d
e
f
g
c Prostaglandins
d
e
f
g
c Intravenous Inotropes
d
e
f
g
c Inhaled NO
d
e
f
g
c Ventilator
d
e
f
g
c Other Mechanism, Specify
d
e
f
g

Specify:

j NONE
k
l
m
n

j LVAD
k
l
m
n
Patient on Ventricular Assist Device:

j RVAD
k
l
m
n
j TAH
k
l
m
n
j LVAD+RVAD
k
l
m
n

VAD Brand1:
Specify:
VAD Brand2:
Specify:

Functional Status:

j Definite Cognitive delay/impairment (verified by IQ
k
l
m
n
score <70 or unambiguous behavioral observation)

j Probable Cognitive delay/impairment (not verified or
k
l
m
n
unambiguous but more likely than not, based on
behavioral observation or other evidence)

j Questionable Cognitive delay/impairment (not judged
k
l
m
n
to be more likely than not, but with some indication of
cognitive delay/impairment such as expressive/receptive
language and/or learning difficulties)
Cognitive Development:

j No Cognitive delay/impairment (no obvious indicators
k
l
m
n
of cognitive delay/impairment)
j Not Assessed
k
l
m
n

j Definite Motor delay/impairment (verified by physical
k
l
m
n
exam or unambiguous behavioral observation)
j Probable Motor delay/impairment (not verified or
k
l
m
n
unambiguous but more likely than not, based on
behavioral observation or other evidence)
j Questionable Motor delay/impairment (not judged to
k
l
m
n
be more likely than not, but with some indications of
motor delay/impairment)

Motor Development:

j No Motor delay/impairment (no obvious indicators of
k
l
m
n
motor delay/impairment)
j Not Assessed
k
l
m
n

j Within One Grade Level of Peers
k
l
m
n
j Delayed Grade Level
k
l
m
n
j Special Education
k
l
m
n

Academic Progress:

j Not Applicable < 5 years old
k
l
m
n
j Status Unknown
k
l
m
n

j Full academic load
k
l
m
n
j Reduced academic load
k
l
m
n
j Unable to participate in academics due to disease or
k
l
m
n
condition

Academic Activity Level:

j Not Applicable < 5 years old/ High School graduate
k
l
m
n
j Status Unknown
k
l
m
n
Previous Transplants:
Organ

Date

Graft Fail Date

The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than
three previous transplants by calling 800-978-4334 or by emailing [email protected].

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

Previous Pancreas Islet Infusion:

Source of Payment:
Primary:
Specify:
Secondary:

Clinical Information: AT LISTING
Date of
Measurement:
Height:

ft.

Weight:

lbs

BMI:

in.

cm %ile ST=
kg

kg/m2

%ile ST=
%ile

ABO Blood Group:

Primary Diagnosis:
Specify:

General Medical Factors:

j No
k
l
m
n
j Type I
k
l
m
n
Diabetes:

j Type II
k
l
m
n
j Type Other
k
l
m
n
j Type Unknown
k
l
m
n
j Diabetes Status Unknown
k
l
m
n

j No dialysis
k
l
m
n

j Hemodialysis
k
l
m
n
Dialysis:

j Peritoneal Dialysis
k
l
m
n
j Dialysis Status Unknown
k
l
m
n
j Dialysis-Unknown Type was performed
k
l
m
n

j No
k
l
m
n
Peptic Ulcer:

j Yes, active within the last year
k
l
m
n
j Yes, not active within the last year
k
l
m
n
j Unknown
k
l
m
n

j No angina
k
l
m
n
j Stable angina - strenuous activity results in angina
k
l
m
n

j Stable angina - ordinary physical activity results in
k
l
m
n
angina
Angina:

j Stable angina - no rest angina; does have angina with
k
l
m
n
less than ordinary activity

j Stable angina - angina with any physical activity or at
k
l
m
n

rest

j Unstable angina
k
l
m
n
j Unknown if angina present
k
l
m
n

Drug Treated Systemic Hypertension:
Symptomatic Cerebrovascular Disease:

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

Symptomatic Peripheral Vascular
Disease:

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

Drug Treated COPD:

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

Pulmonary Embolism:

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

Any Previous Transfusions:

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

Any previous Malignancy:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
c Skin Melanoma
d
e
f
g
c Skin Non-Melanoma
d
e
f
g
c CNS Tumor
d
e
f
g
c Genitourinary
d
e
f
g
c Breast
d
e
f
g

Specify Type:

c Thyroid
d
e
f
g
c Tongue/Throat/Larynx
d
e
f
g

c Lung
d
e
f
g
c Leukemia/Lymphoma
d
e
f
g
c Liver
d
e
f
g
c Other, specify
d
e
f
g
Specify:
Most Recent Serum Creatinine:

Total Serum Albumin:

ST=
mg/dl
g/dl

ST=

Heart Medical Factors:
Sudden Death:

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

Antiarrhythmics:

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

Amiodarone:

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

Implantable Defibrillator:

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

Infection Requiring IV Drug Therapy
within 2/wks prior to listing:

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

Exercise Oxygen Consumption:

ST=
ml/min/kg

Most Recent Hemodynamics:

Inotropes/Vasodilators:
ST=

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

PA (sys) mm/Hg:
ST=

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

PA (dia) mm/Hg:
ST=

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

PA (mean) mm/Hg:
ST=

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

PCW (mean) mm/Hg:
ST=

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

CO L/min:

History of Cigarette Use:

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
Duration of Abstinence:

j 13-24 months
k
l
m
n
j 25-36 months
k
l
m
n
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 Use:

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

Prior thoracic surgery other than prior
transplant:

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

If yes, number of prior sternotomies:
If yes, number of prior thoracotomies:
Prior congenital cardiac surgery:

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

If yes, palliative surgery:

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

If yes, corrective surgery:

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