Form 24b Intestine Candidate Pediatric Registration

Records
Pediatric Intestine 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 provided. Based on
B.

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

g Puerto Rican (Island)
c
d
e
f

c Haitian
d
e
f
g

c Cuban
d
e
f
g

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

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

Native Hawaiian or Other Pacific Islander

White

c Native Hawaiian
d
e
f
g

c European Descent
d
e
f
g

c Guamanian or Chamorro
d
e
f
g

c Arab or Middle Eastern
d
e
f
g

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

g North African (non-Black)
c
d
e
f
c White: Other
d
e
f
g
c White: Not Specified/Unknown
d
e
f
g

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 Ventilator
d
e
f
g
c Artificial Liver
d
e
f
g
c Other Mechanism, Specify
d
e
f
g

Specify:

Functional Status:

j Definite Cognitive delay/impairment (verified by IQ score
k
l
m
n
<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)
Cognitive Development:

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

j No Cognitive delay/impairment (no obvious indicators of
k
l
m
n
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)
Motor Development:

j Questionable Motor delay/impairment (not judged to be
k
l
m
n
more likely than not, but with some indications of motor
delay/impairment)
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

%ile ST=
%ile

kg/m2
ABO Blood Group:

Primary Diagnosis:
Specify:
Secondary 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
k
l
m
n

j Yes, and documented Coronary Artery Disease
k
l
m
n
Angina:

j Yes, with no documented Coronary Artery Disease
k
l
m
n
j Yes, but Coronary Artery Disease unknown
k
l
m
n
j Status Unknown
k
l
m
n

Drug Treated Systemic Hypertension:

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

Symptomatic Cerebrovascular Disease:

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

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
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
c Thyroid
d
e
f
g
Specify Type:

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 Hepatoblastoma
d
e
f
g
c Hepatocellular carcinoma
d
e
f
g

c Other, specify
d
e
f
g
Specify:

Most Recent Serum Creatinine:

mg/dl ST=

Total Serum Albumin:

g/dl

Total Bilirubin:

mg/dl ST=

ST=

Intestine Medical Factors
Loss of two or more vascular access
sites:

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

Intestine Neoplasm:

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

History of Portomesenteric Vein
Thrombosis:

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

History of TIPSS:

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

Variceal Bleeding in the Last 2 Weeks:

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

Recurrent Sepsis:

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

Fungal Sepsis:

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

Unmanageable Fluid-Electrolyte
Losses:

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

"Non-Reconstructible" GI Tract:

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