Form 1 Living Donor Registration

Records
Living Donor Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2011
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 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:

Donor Information
Donor Name:
UNOS Donor ID #:

Address:

Home City:

State:

Zip Code:
-

Home Phone:

Work Phone:

Email:

SSN:

Date of Birth:

Gender:

Male

Single
Married
Divorced
Marital Status at Time of Donation:

Separated
Life Partner
Widowed
Unknown

Female

ABO Blood Group:

Biological, blood related Parent
Biological, blood related Child
Biological, blood related Identical Twin
Biological, blood related Full Sibling
Biological, blood related Half Sibling
Biological, blood related Other Relative: SPECIFY
Donor Type:

Non-Biological, Spouse
Non-Biological, Life Partner
Non-Biological, Unrelated: Paired Donation
Non-Biological, Unrelated: Non-Directed Donation (Anonymous)
Non-Biological, Living/Deceased Donation
Non-Biological, Unrelated: Domino
Non-Biological, Other Unrelated Directed Donation: Specify

Specify:

Ethnicity/Race:
(select all origins that apply)
American Indian or Alaska Native
American Indian

Asian
Asian Indian/Indian SubContinent

Eskimo
Chinese
Aleutian
Filipino
Alaska Indian
Japanese
American Indian or Alaska Native: Other
Korean
American Indian or Alaska Native: Not
Specified/Unknown

Vietnamese

Asian: Other
Asian: Not Specified/Unknown
Black or African American

Hispanic/Latino

African American

Mexican

African (Continental)

Puerto Rican (Mainland)

West Indian

Puerto Rican (Island)

Haitian

Cuban

Black or African American: Other

Hispanic/Latino: Other

Black or African American: Not Specified/Unknown
Native Hawaiian or Other Pacific Islander

Hispanic/Latino: Not
Specified/Unknown
White

Native Hawaiian

European Descent

Guamanian or Chamorro

Arab or Middle Eastern

Samoan

North African (non-Black)

Native Hawaiian or Other Pacific Islander: Other

White: Other

Native Hawaiian or Other Pacific Islander: Not
Specified/Unknown

White: Not Specified/Unknown

U.S. CITIZEN
Citizenship:

RESIDENT ALIEN
NON-RESIDENT ALIEN, Year Entered US

Year of Entry into U.S.:

NONE
GRADE SCHOOL (0-8)
HIGH SCHOOL (9-12) or GED
Highest Education Level:
ATTENDED COLLEGE/TECHNICAL SCHOOL
ASSOCIATE/BACHELOR DEGREE
POST-COLLEGE GRADUATE DEGREE

N/A (< 5 YRS OLD)
UNKNOWN

Did the donor have health insurance:

YES

NO

UNK

Functional Status:

No Limitations
Limited Mobility
Physical Capacity: (check one)
Wheelchair bound or more limited
Unknown

Working for Income:

YES

NO

UNK

Disability
Insurance Conflict
Inability to Find Work
Donor Choice - Homemaker
If No, Not Working Due To: (check one)
Donor Choice - Student Full Time/Part Time
Donor Choice - Retired
Donor Choice - Other
Unknown

Working Full Time
If Yes:

Working Part Time due to Disability
Working Part Time due to Insurance Conflict

Working Part Time due to Inability to Find Full Time Work
Working Part Time due to Donor Choice
Working Part Time Reason Unknown
Working, Part Time vs. Full Time Unknown

Pre-Donation Clinical Information
Viral Detection:
Have any of the following viruses ever been
tested for: HIV, CMV, HBV, HCV, EBV

HIV
Test

YES

NO

YES

NO

Result

Positive
Negative
Screening:
Not Done
UNK/Cannot Disclose

Positive
Negative
Confirmation:
Not Done
UNK/Cannot Disclose

Was there clinical disease (ARC, AIDS):

YES

NO

UNK

Positive
Negative
Antibody:
Not Done
UNK/Cannot Disclose

Positive
Negative
RNA:
Not Done
UNK/Cannot Disclose

CMV
Test

YES

NO

Result

Positive
Negative
CMV:
Not Done
UNK/Cannot Disclose

Was there clinical disease:

YES

NO

UNK

Positive
Negative
IgG:
Not Done
UNK/Cannot Disclose

Positive
Negative
IgM:
Not Done
UNK/Cannot Disclose

Positive
Nucleic Acid Testing:

Negative
Not Done

UNK/Cannot Disclose

Positive
Negative
Culture:
Not Done
UNK/Cannot Disclose

HBV
Test
Was there clinical disease:

YES

NO

YES

NO

Result

UNK

Positive
Negative
Liver Histology:
Not Done
UNK/Cannot Disclose

Positive
Negative
Core Antibody:
Not Done
UNK/Cannot Disclose

Positive
Negative
Surface Antigen:
Not Done
UNK/Cannot Disclose

HBV DNA:

Positive

Negative
Not Done
UNK/Cannot Disclose

Positive
Negative
HDV (Delta Virus):
Not Done
UNK/Cannot Disclose

HCV
Test
Was there clinical disease:

YES

NO

YES

NO

Result

UNK

Positive
Negative
Liver Histology:
Not Done
UNK/Cannot Disclose

Positive
Negative
Antibody:
Not Done
UNK/Cannot Disclose

Positive
Negative
RIBA:
Not Done
UNK/Cannot Disclose

Positive
Negative
HCV RNA:
Not Done
UNK/Cannot Disclose

EBV
Test
Was there clinical disease:

YES

NO

YES

NO

Result

UNK

Positive
Negative
IgG:
Not Done
UNK/Cannot Disclose

Positive
Negative
IgM:
Not Done
UNK/Cannot Disclose

Positive
Negative
EBV DNA:
Not Done
UNK/Cannot Disclose

Pre-Donation Height and Weight
Height:
Weight:

ft
lb

in

cm

ST=

kg

ST=

NO
SKIN - SQUAMOUS, BASAL CELL
SKIN - MELANOMA
CNS TUMOR - ASTROCYTOMA
CNS TUMOR - GLIOBLASTOMA
MULTIFORME
CNS TUMOR - MEDULLOBLASTOMA
CNS TUMOR - NEUROBLASTOMA
CNS TUMOR - ANGIOBLASTOMA
CNS TUMOR - MENINGIOMA
CNS TUMOR - OTHER
GENITOURINARY - BLADDER
History of Cancer:
GENITOURINARY - UTERINE CERVIX
GENITOURINARY - UTERINE BODY
ENDOMETRIAL
GENITOURINARY - UTERINE BODY
CHORIOCARCINOMA
GENITOURINARY - VULVA
GENITOURINARY - OVARIAN
GENITOURINARY - PENIS, TESTICULAR
GENITOURINARY - PROSTATE
GENITOURINARY - KIDNEY
GENITOURINARY - UNKNOWN
GASTROINTESTINAL - ESOPHAGEAL
GASTROINTESTINAL - STOMACH

GASTROINTESTINAL - SMALL INTESTINE
GASTROINTESTINAL - COLO-RECTAL
GASTROINTESTINAL - LIVER & BILIARY
TRACT
GASTROINTESTINAL - PANCREAS
BREAST
THYROID
TONGUE/THROAT
LARYNX
LUNG (include bronchial)
LEUKEMIA/LYMPHOMA
UNKNOWN
OTHER, SPECIFY
Specify:
Cancer Free Interval:

History of Cigarette Use:

years

YES

ST=

NO

0-10
11-20
21-30
If Yes, Check # pack years:

31-40
41-50
>50
Unknown pack years

0-2 months
3-12 months
13-24 months
25-36 months
Duration of Abstinence:

37-48 months
49-60 months
>60 months
Continues To Smoke
Unknown duration

Other Tobacco Used:

Diabetes:

YES

NO

UNK

YES

NO

UNK

Insulin
Treatment:

Oral Hypoglycemic Agent
Diet

Pre-Donation Liver Clinical Information
Total Bilirubin:
SGOT/AST:
SGPT/ALT:
Alkaline Phosphatase:
Serum Albumin:
Serum Creatinine:
INR:

mg/dl

ST=

U/L

ST=

U/L

ST=

units/L

ST=

g/dl

ST=

mg/dl

ST=
ST=

Liver Biopsy:

YES

% Macro vesicular fat:
% Micro vesicular fat:

NO

%

ST=

%

ST=

Pre-Donation Kidney Clinical Information

NO
YES, 0-5 YEARS
YES, 6-10 YEARS
History of Hypertension:
YES, >10 YEARS
YES, UNKNOWN DURATION
UNKNOWN
If Yes, Method of Control:
Diet:

Diuretics:

Other Hypertensive Medication:

Serum Creatinine:

Preoperative Blood Pressure Systolic:
Preoperative Blood Pressure Diastolic:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

mg/dl

ST=

mm/Hg

ST=

mm/Hg

ST=

Urinalysis:

Positive
Urine Protein:
Negative

Not Done
Unknown
or
Protein-Creatinine Ratio:

Kidney Biopsy:

YES

NO

0-5
6-10
11-15
Glomerulosclerosis:
16-20
20+
Indeterminate

Pre-Donation Lung Clinical Information
Before
Bronchodilators
FVC % predicted:

FEV1 % predicted:

FEF (25-75%) % predicted:

TLC % predicted:

Diffusing lung capacity corrected for alveolar
volume % predicted:

After
Bronchodilators
ST=

ST=

ST=

ST=

ST=

ST=

ST=

ST=

ST=

PaO2 on room air:
mm/Hg

ST=

Liver Surgical Information

Left Lateral Segment (Peds)
Left Lobe
Type of Transplant Graft:
Right Lobe
Domino Whole Liver

Kidney Surgical Information

LEFT KIDNEY
RIGHT KIDNEY
Type of Transplant Graft:
EN-BLOC
Sequential Kidney

Transabdominal
Flank(retroperitoneal)
Intended Procedure Type:
Laparoscopic Not Hand-assisted
Laparoscopic Hand-assisted

Conversion from Laparoscopic to Open:

YES

NO

Lung Surgical Information

LOBE, RIGHT
Type of Transplant Graft:
LOBE, LEFT

Open
Procedure Type:
Video Assisted Thoracoscopic

Conversion from Thoracoscopic to Open:

YES

NO

Intra-operative Complications:

YES

NO

Sacrifice of Second Lobe Specify
Anesthetic Complication Specify
Arrhythmia Requiring Therapy
Cerebrovasular Accident
If Yes, Specify:
Phrenic Nerve Injury
Brachial Plexus Injury
Breast Implant Rupture
Other Specify

RML
RUL
Sacrifice of Second Lobe, Specify:
LUL
Lingular
Anesthetic Complication Specify:

Medical therapy
Arrhythmia requiring therapy:
Cardioversion
Other Specify:

Post-Operative Information
Date of Initial Discharge:

Living
Donor Status:
Dead

Date Last Seen or Death:

Cause of Death:
Other Specify:

Non-Autologous Blood Administration:

YES

NO

If Yes, Number of Units:
PRBC
Platelets
FFP

Liver Related Post-Operative Complications (In first 6 weeks post-donation)
Biliary Complications:

YES

NO

UNK

If Yes, Specify:
Grade 1 – Bilious JP drainage more than 10 days
Grade 2 – Interventional procedure (ERCP, PTC, percutaneous
drainage, etc.)
Grade 3 – Surgical Intervention

Date of surgery:

Vascular Complications Requiring Intervention:
YES

NO

UNK

If Yes, Specify:
Portal Vein
Hepatic Vein
Hepatic Artery
Pulmonary Embolus
Deep Vein Thrombosis
Other, Specify
Specify:

Other Complications Requiring Intervention:

YES

NO

UNK

If Yes, Specify:
Renal insufficiency requiring dialysis
Ascites
Line or IV complication
Pneumothorax
Pneumonia
Wound Complication
Brachial Nerve Injury
Other, specify
Specify:

Reoperation:
If yes, specify reason for reoperation (during first
six weeks):

YES

NO

UNK

Liver Failure Requiring Transplant

Date:

Bleeding Complications

Date:

Hernia Repair

Date:

Bowel Obstruction

Date:

Vascular Complications

Date:

Other Specify

Date:

Other Specify:

Any Readmission After Initial Discharge:
If yes, specify reason for readmission (during
first six weeks):

YES

NO

Wound Infection
Fever

UNK

Bowel Obstruction
Pleural Effusion
Biliary Complications
Vascular Complications
Other, specify
Other Specify:
If Yes, Date of First Readmission:

Other Interventional Procedures:

YES

NO

UNK

If Yes, Specify Procedure:
Date of Procedure:

Kidney Related Post-Operative Complications (In first 6 weeks post-donation)
Vascular Complications Requiring Intervention:
YES

NO

UNK

If Yes, Specify:
Renal Vein
Renal Artery
Aorta
Vena Cava
Pulmonary Embolus
Deep Vein Thrombosis
Other, specify
Specify:

Other Complications Requiring Intervention:

YES

NO

UNK

If Yes, Specify:
Renal insufficiency requiring dialysis
Ascites
Line or IV complication
Pneumothorax
Pneumonia
Wound Complication
Brachial Nerve Injury
Other, specify
Other Specify:

Reoperation:
If yes, specify reason for reoperation (during first
six weeks):

YES

NO

UNK

Bleeding

Date:

Hernia Repair

Date:

Bowel Obstruction

Date:

Vascular

Date:

Other Specify

Date:

Other Specify:

Any Readmission After Initial Discharge:
If yes, specify reason for readmission (during
first six weeks):

YES

NO

Wound Infection
Fever
Bowel Obstruction
Pleural Effusion

UNK

Vascular Complications
Other, specify
Other Specify:
If Yes, Date of First Readmission:

Other Interventional Procedures:

YES

NO

UNK

If Yes, Specify Procedure:
Date of Procedure:

Lung Related Post-Operative Complications (In first 6 weeks post-donation)
Post-operative complications during the initial
hospitalization:

YES

NO

If Yes, Specify:
Arrhythmia requiring therapy
Bleeding requiring surgical or therapeutic bronchoscopic
intervention
Bowel obstruction or ileus not requiring surgical intervention
Bowel obstruction or ileus requiring surgical intervention
Bronchial Stenosis/Stricture not requiring surgical or therapeutic
bronchoscopic intervention
Bronchial Stenosis/Stricture requiring surgical or therapeutic
bronchoscopic intervention
Bronchopleural Fistula requiring surgical or therapeutic
bronchoscopic intervention
Cerebrovascular Accident
Deep Vein Thrombosis
Empyema requiring therapeutic surgical intervention
Epidural-Related Complication

Line or IV Complication
Loculated pleural effusion requiring surgical intervention
Pericardial tamponade or pericarditis requiring surgical
intervention
Pericarditis not requiring surgical intervention
Peripheral Nerve Injury
Phrenic Nerve Injury
Placement of Additional Thoracostomy Tube(s), Specify
Indication
Pneumonia/Atelectasis
Prolonged (>14days) Thoracostomy Tube Requirement
Pulmonary Artery Embolus or Thrombosis
Pulmonary Vein or Left Atrial Thrombosis
Wound Complication
Wound infection requiring surgical intervention
Other Specify

Medical therapy
Arrhythmia requiring therapy:

Cardioversion
Electrophysiologic Ablation

Pneumothorax
Placement of Additional Thoracostomy Tube(s),
Indication:

Pleural effusion
Empyema

Other Specify:

Any Readmission After Initial Discharge:

YES

NO

UNK

If yes, specify reason for readmission (during
first six weeks):

Wound Infection
Fever
Bowel Obstruction
Pleural Effusion
Vascular Complications
Other, specify

Specify:
If Yes, Date of First Readmission:

Post-Operative Clinical Information (Within 6 weeks post-donation)
Most Recent Date of Tests:

Height:
Weight:

ft

in

lb

cm

ST=

kg

ST=

Kidney Post-Operative Clinical Information
Serum Creatinine:

Post-Op Blood Pressure Systolic:
Post-Op Blood Pressure Diastolic:

mg/dl

ST=

mm/Hg

ST=

mm/Hg

ST=

Urinalysis:

Positive
Negative
Urine Protein:
Not Done
Unknown

or
Protein-Creatinine Ratio:

Donor Developed Hypertension Requiring
Medication:

YES

NO

UNK

Liver Post-Operative Clinical Information
Total Bilirubin:
SGOT/AST:
SGPT/ALT:
Alkaline Phosphatase:
Serum Albumin:
Serum Creatinine:

mg/dl

ST=

U/L

ST=

U/L

ST=

units/L

ST=

g/dl

ST=

mg/dl

ST=

INR:

ST=

Organ Recovery
Organ Recovery Date:
Did organ recovery and transplant occur at the
same center:

Organ(s) Recovered
Donor Recovery Facility:
Donor Workup Facility:

UNOS View Only
Comments:

YES

Recipient Name (Last, First)

NO

Recipient SSN#