52 Vascular Composite Allograft Transplant Recipient Follow

	Fields to be completed by members
	Form Section	Field Label	Notes
	Recipient Information	Recipient First Name	Display Only - Cascades from Removal Worksheet
	Recipient Information	Recipient Last Name	Display Only - Cascades from Removal Worksheet
	Recipient Information	Recipient Middle Initial	Display Only - Cascades from Removal Worksheet
	Recipient Information	DOB	Display Only - Cascades from Removal Worksheet
	Recipient Information	SSN	Display Only - Cascades from Removal Worksheet
	Recipient Information	Gender	Display Only - Cascades from Removal Worksheet
	Recipient Information	HIC	Display Only - Cascades from TRR
	Recipient Information	Transplant Date	Display Only - Cascades from Removal Worksheet
	Recipient Information	State of Permanent Residence
	Recipient Information	Permanent zip code
	Provider Information	Treating Reconstructive Surgeon Name
	Provider Information	Treating Reconstructive Surgeon NPI#
	Provider Information	Treating Transplant Physician Name
	Provider Information	Treating Transplant Physician NPI#
	Provider Information	Follow-up Care Provided By:
	Donor Information	UNOS Donor ID #	Display Only - Cascades from Removal Worksheet
	Donor Information	Donor Type	Display Only - Cascades from Removal Worksheet
	Donor Information	OPO	Display Only - Cascades from Removal Worksheet
	Patient Status	Date Last Seen, Retransplanted, or Death
	Patient Status	Patient Status
	Patient Status	Primary Cause of Death
	Patient Status	Primary Cause of Death - Other Specify
	Patient Status	Has patient been hospitalized since the Last Patient Status Date
	Patient Status	Number of Hospitalizations
	Socio-Demographic Information	Working for income
	Socio-Demographic Information	Working for income - If Yes, indicate the recipient's working status
	Socio-Demographic Information	Working for income - If No, Not Working Due To
	Socio-Demographic Information - Source of Payment	Grant funding
	Socio-Demographic Information - Source of Payment	Institutional funding
	Socio-Demographic Information - Source of Payment	Primary Source of Payment
	Socio-Demographic Information - Source of Payment	Primary Source of Payment - Foreign Government, Specify
	Socio-Demographic Information - Source of Payment	Secondary Source of Payment
	Functional Status	Cognitive Development
	Functional Status	Motor Development
	Functional Status	Psychosocial consult performed
	Functional Status - SF-36 score - Physical Health	Physical Functioning (PF) score
	Functional Status - SF-36 score - Physical Health	Role-Physical (RP) score
	Functional Status - SF-36 score - Physical Health	Bodily Pain (BP) score
	Functional Status - SF-36 score - Physical Health	General Health (GH) score
	Functional Status - SF-36 score - Mental Health	Vitality (VT) score
	Functional Status - SF-36 score - Mental Health	Social Functioning (SF) score
	Functional Status - SF-36 score - Mental Health	Role-Emotional (RE) score
	Functional Status - SF-36 score - Mental Health	Mental Heath (MH) score
	Functional Status - Upper Limb	DASH Score
	Functional Status - Upper Limb	Carroll Test Score - Left
	Functional Status - Upper Limb	Carroll Test Score - Right
	Functional Status - Upper Limb	Sensibility Test - Semmes Weinstein - Left
	Functional Status - Upper Limb	Sensibility Test - Semmes Weinstein - Right
	Functional Status - Craniofacial	Olfactory function restored
	Functional Status - Craniofacial - Sensory Testing	2 point discrimination (mm)
	Functional Status - Craniofacial - Sensory Testing - Hot/cold testing	Can feel heat
	Functional Status - Craniofacial - Sensory Testing - Hot/cold testing	Can feel cold
	Functional Status - Craniofacial - Motor function	Oral competence
	Functional Status - Craniofacial - Motor function	Corneal protection
	Functional Status - Craniofacial	Functional occlusion restored
	Functional Status - Craniofacial	Decannulation (if the patient had a tracheostomy)
	Functional Status - Craniofacial	Feeding Tube Removed (if the patient had a feeding tube to start with)
	Functional Status - Craniofacial - Speech Intelligibility Tests	Speaking rate
	Functional Status - Craniofacial - Speech Intelligibility Tests	Percent Intelligibility
	Clinical Information	Height (inches)
	Clinical Information	Weight (lbs)
	Clinical Information	BMI (Body Mass Index)	Display Only - Calculated
	Clinical Information - Noncompliance	Immunosuppression
	Clinical Information - Noncompliance	Rehabilitation
	Clinical Information - Noncompliance	Level of Activity
	Clinical Information - Noncompliance	Other
	Clinical Information - Noncompliance	Other - Other Specify
	Clinical Information	Graft Status
	Clinical Information	Date of Graft Failure
	Clinical Information - Causes of Graft Failure	Acute Rejection
	Clinical Information - Causes of Graft Failure	Acute Rejection - Banff score
	Clinical Information - Causes of Graft Failure	Acute Rejection - Visual skin changes
	Clinical Information - Causes of Graft Failure	Chronic Rejection
	Clinical Information - Causes of Graft Failure	Chronic Rejection - Visual skin changes
	Clinical Information - Causes of Graft Failure	Ischemia
	Clinical Information - Causes of Graft Failure	Sepsis / Infection
	Clinical Information - Causes of Graft Failure	Trauma
	Clinical Information - Causes of Graft Failure	Patient requested removal
	Clinical Information - Causes of Graft Failure	Non-compliance: immunosuppression
	Clinical Information - Causes of Graft Failure	Non-compliance: rehabilitation
	Clinical Information - Causes of Graft Failure	Non-compliance: level of activity
	Clinical Information - Causes of Graft Failure	Other
	Clinical Information - Causes of Graft Failure	Other - Other Specify
	Clinical Information - Most Recent Lab Data	Serum Creatinine (mg/dL)
	Clinical Information - Most Recent Lab Data	Hemoglobin A1c (%)
	Clinical Information - Most Recent Lab Data	Donor Specific Antibodies (DSA)
	Clinical Information	Did patient have any acute rejection episodes during the follow-up period
	Clinical Information	Did patient have any acute rejection episodes during the follow-up period - Number of episodes
	Clinical Information	{For each episode} Date of acute rejection diagnosis
	Clinical Information	{For each episode} Acute rejection was treated
	Clinical Information	{For each episode} Visual skin changes
	Clinical Information	{For each episode} Biopsy was done to confirm acute rejection
	Clinical Information	{For each episode} Banff Score
	Clinical Information - Complications	New onset diabetes
	Clinical Information - Complications	Metabolic Complications
	Clinical Information - Complications	Infectious Complications
	Clinical Information - Complications	Other Complications
	Clinical Information - Complications	Other Complications - Other Specify
	Clinical Information	Post Transplant Malignancy
	Clinical Information - Post-transplant Malignancy	Donor Related
	Clinical Information - Post-transplant Malignancy - Donor Related	Diagnosis date:
	Clinical Information - Post-transplant Malignancy - Donor Related	Tumor type
	Clinical Information - Post-transplant Malignancy	Recurrence of Pre-Tx Tumor
	Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy	Date of recurrence
	Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy	Type of pre-existing tumor
	Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy	Type of pre-existing tumor - Other, Specify
	Clinical Information - Post-transplant Malignancy	De Novo Solid Tumor
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Diagnosis date
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Skin: //squamous cell:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Skin: //basal cell:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Skin: //melanoma:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Kaposi's sarcoma: cutaneous:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Kaposi's sarcoma: visceral:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Brain:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Brain: //Other specify:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Renal carcinoma - specify site(s):
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Carcinoma of vulva, perineum or penis, scrotum:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Carcinoma of the uterus:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Ovarian:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Testicular:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Esophagus:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Stomach:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Small intestine:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Pancreas:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Larynx:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Tongue, throat:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Thyroid:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Bladder:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Breast:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Prostate:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Colo-rectal:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Primary hepatic tumor:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Metastatic liver tumor:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Lung:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types://Leukemia:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Sarcomas:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Other cancers:
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Other Cancers: //Site(s):
	Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Primary unknown:
	Clinical Information - Post-transplant Malignancy	De Novo Lymphoproliferative disease and Lymphoma
	Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma	PTLD: //Diagnosis date:
	Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma	PTLD: //Pathology:
	Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma	PTLD: Pathology: //Other Specify:
	Treatment	Antiviral
	Treatment	Antibiotic
	Treatment	Antifungal
	Topical Immunosuppressive Medications	Immunosuppression medications
	Topical Immunosuppressive Medications	Immunosuppression medications - Other Specify
	Topical Immunosuppressive Medications	Previous maintenance indication
	Topical Immunosuppressive Medications	Current maintenance indication
	Topical Immunosuppressive Medications	Anti-rejection indication
	Non-Topical Immunosuppressive Medications	Immunosuppression medications
	Non-Topical Immunosuppressive Medications	Immunosuppression medications - Other Specify
	Non-Topical Immunosuppressive Medications	Previous maintenance indication
	Non-Topical Immunosuppressive Medications	Current maintenance indication
	Non-Topical Immunosuppressive Medications	Anti-rejection indication
		Public Burden Statement