11 Thoracic Follow-up

Records
Adult 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
other data may be provided. Based on data provided through the online TIEDI
fields are not required in every case, they are not marked with a red asterisk.

B.

B.

application. Currently in the worksheet, a red asterisk is displayed by fields that are required, independent of what

application, additional fields that are dependent on responses provided in these required fields may become required as well. However, since those

Recipient Information
Name:

DOB:

SSN:

Gender:

HIC:

Tx Date:

Previous Follow-Up:

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
j Acute Rejection
k
l
m
n
Primary Cause of Graft Failure:

j Chronic Rejection/Atherosclerosis
k
l
m
n
j Other, Specify
k
l
m
n