Form 11b Thoracic Pediatric Follow-up

Records
Pediatric Thoracic Transplant Recipient 6 Month Follow-Up Worksheet
The revised worksheet sample is for reference purposes only and is pending OMB approval.
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI

B.

application. Currently in the worksheet, a red asterisk is
B.

displayed by fields that are required, independent of what other data may be 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.

Recipient Information
Name:

DOB:

SSN:

Gender:

HIC:

Tx Date:

Previous FollowUp:

Previous Px Stat
Date:

Transplant Discharge Date:
State of Permanent Residence:
Zip Code:

-

Patient Status
Date: Last Seen, Retransplanted or Death

j LIVING
k
l
m
n
Patient Status:

j DEAD
k
l
m
n
j RETRANSPLANTED
k
l
m
n

Primary Cause of Death:
Specify:

Contributory Cause of Death:
Specify:

Contributory Cause of Death:
Specify:

Clinical Information
Graft Status:

j Functioning n
k
l
m
n
j Failed
k
l
m

If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Date of Graft Failure:

j Primary Non-Function
k
l
m
n
Primary Cause of Graft Failure:

j Acute Rejection
k
l
m
n
j Chronic Rejection/Atherosclerosis
k
l
m
n

j Other, Specify
k
l
m
n
Current A titer:

Sample Date:

Current B titer:

Sample Date: