1 Thoracic Heart Adult 6 month Follow-up

Records
Adult Thoracic Transplant Recipient 6 Month Follow-Up Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2011
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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
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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.

Name:

DOB:

SSN:

Gender:

HIC:
Previous Follow-Up:

Tx Date:
Transplant Recipient Registration

Previous Px Stat Date:

Transplant Discharge Date:

State of Permanent Residence:

Zip Code:

-

Recipient Center:
Followup Center:

UNOS Donor ID #:
Donor Type:

Date: Last Seen, Retransplanted or Death

LIVING
Patient Status:

DEAD

RETRANSPLANTED

Primary Cause of Death:

Specify:

Contributory Cause of Death:

Specify:

Contributory Cause of Death:

Specify:

Graft Status:

Functioning

Failed

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:

Primary Non-Function

Acute Rejection
Primary Cause of Graft Failure:
Chronic Rejection/Atherosclerosis

Other, Specify

Other, Specify: