51 Vascular Composite Allograft Transplant Recipient Regist

	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
	Recipient Information	Transplant Date	Display Only - Cascades from Removal Worksheet
	Recipient Information	State of Permanent Residence
	Recipient Information	Permanent Zip Code
	Provider Information	Recipient Center	Display Only - Cascades from Removal Worksheet
	Provider Information	Lead Reconstructive Surgeon Name
	Provider Information	Lead Reconstructive Surgeon NPI#
	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 - Transplant hospitalization	Date of Admission to Transplant Center
	Patient Status - Transplant hospitalization	Date of Discharge from Hospital
	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
	Socio-Demographic Information: Pre-Transplant	Highest Education Level
	Socio-Demographic Information: Pre-Transplant	Working for income
	Socio-Demographic Information: Pre-Transplant	Working for income - If Yes, indicate the recipient's working status
	Socio-Demographic Information: Pre-Transplant	Working for income - If No, Not Working Due To
	Socio-Demographic Information: Pre-Transplant - Source of Payment	Grant Funding
	Socio-Demographic Information: Pre-Transplant - Source of Payment	Institutional Funding
	Socio-Demographic Information: Pre-Transplant - Source of Payment	Primary Source of Payment
	Socio-Demographic Information: Pre-Transplant - Source of Payment	Primary Source of Payment - Foreign Government, Specify
	Socio-Demographic Information: Pre-Transplant - Source of Payment	Secondary Source of Payment
	Clinical Information: Pre-transplant	Height (inches)
	Clinical Information: Pre-transplant	Weight (lbs)
	Clinical Information: Pre-transplant	BMI (Body Mass Index)	Display Only - Calculated
	Clinical Information: Pre-transplant	Primary Diagnosis for Transplant
	Clinical Information: Pre-transplant	Primary Diagnosis for Transplant - Other Specify
	Clinical Information: Pre-transplant - Amount of Tissue Loss	Craniofacial
	Clinical Information: Pre-transplant - Amount of Tissue Loss	Craniofacial - Partial Face - Specify anatomic structures missing
	Clinical Information: Pre-transplant - Amount of Tissue Loss	Craniofacial - Other Specify
	Clinical Information: Pre-transplant - Amount of Tissue Loss	Abdominal Wall (cm2)
	Clinical Information: Pre-transplant - Amount of Tissue Loss	Other VCA Organ Type - Other Specify
	Clinical Information: Pre-transplant - Level of Amputation	Upper Limb, Left
	Clinical Information: Pre-transplant - Level of Amputation	Upper Limb, Left - Other Specify
	Clinical Information: Pre-transplant - Level of Amputation	Upper Limb, Right
	Clinical Information: Pre-transplant - Level of Amputation	Upper Limb, Right - Other Specify
	Clinical Information: Pre-transplant - Level of Amputation	Lower Limb, Left
	Clinical Information: Pre-transplant - Level of Amputation	Lower Limb, Left - Other Specify
	Clinical Information: Pre-transplant - Level of Amputation	Lower Limb, Right
	Clinical Information: Pre-transplant - Level of Amputation	Lower Limb, Right - Other Specify
	Clinical Information: Pre-transplant	Previous Transplants (VCA or non-VCA organs)
	Clinical Information: Pre-transplant	Previous skin graft(s)
	Clinical Information: Pre-transplant	Was patient hospitalized during the last 90 days prior to the transplant admission
	Clinical Information: Pre-transplant	Medical condition at time of transplant
	Clinical Information: Pre-transplant	Patient on Life Support
	Clinical Information: Pre-transplant	Patient on Life Support - Ventilator
	Clinical Information: Pre-transplant	Patient on Life Support - Other Mechanism
	Clinical Information: Pre-transplant	Patient on Life Support - Other Mechanism - Other Specify
	Clinical Information: Pre-transplant - Viral Detection	HIV Serostatus
	Clinical Information: Pre-transplant - Viral Detection	CMV Status
	Clinical Information: Pre-transplant - Viral Detection	HBV Core Antibody
	Clinical Information: Pre-transplant - Viral Detection	HBV Surface Antigen
	Clinical Information: Pre-transplant - Viral Detection	HCV Serostatus
	Clinical Information: Pre-transplant - Viral Detection	EBV Serostatus
	Clinical Information: Pre-transplant	Any tolerance induction technique used
	Clinical Information: Pre-transplant	Pre-transplant blood transfusions
	Clinical Information: Pre-transplant	Number of pre-transplant pregnancies (which may or may not have resulted in a live birth)
	Clinical Information: Pre-transplant	Malignancies prior to transplant
	Clinical Information: Pre-transplant	Malignancies prior to transplant - If Yes, Specify Type (select all that apply)
	Clinical Information: Pre-transplant - Pre-Transplant Labs	Serum Creatinine (mg/dL)
	Clinical Information: Pre-transplant - Pre-Transplant Labs	Hemoglobin A1c (%)
	Clinical Information: Pre-transplant - Pre-Transplant Labs	Calculated PRA (CPRA) at transplant (%)
	Clinical Information: Pre-transplant - Pre-Transplant Labs	Donor Crossmatch Result
	Clinical Information: Pre-transplant - Risk Factors	Coagulopathies
	Clinical Information: Pre-transplant - Risk Factors	Other Risk Factors
	Clinical Information: Pre-transplant - Risk Factors	Other Risk Factors - Other Specify
	Functional Status: Pre-transplant	Cognitive Development
	Functional Status: Pre-transplant	Motor Development
	Functional Status: Pre-transplant - SF-36 score - Physical Health	Physical Functioning (PF) score
	Functional Status: Pre-transplant - SF-36 score - Physical Health	Role-Physical (RP) score
	Functional Status: Pre-transplant - SF-36 score - Physical Health	Bodily Pain (BP) score
	Functional Status: Pre-transplant - SF-36 score - Physical Health	General Health (GH) score
	Functional Status: Pre-transplant - SF-36 score - Mental Health	Vitality (VT) score
	Functional Status: Pre-transplant - SF-36 score - Mental Health	Social Functioning (SF) score
	Functional Status: Pre-transplant - SF-36 score - Mental Health	Role-Emotional (RE) score
	Functional Status: Pre-transplant - SF-36 score - Mental Health	Mental Heath (MH) score
	Functional Status: Pre-transplant - Upper Limb - Pre-Transplant	DASH Score
	Functional Status: Pre-transplant - Upper Limb - Pre-Transplant	Carroll Test Score - Left
	Functional Status: Pre-transplant - Upper Limb - Pre-Transplant	Carroll Test Score - Right
	Clinical Information: Transplant Procedure	Multiple Graft Recipient
	Clinical Information: Transplant Procedure	Were extra allograft vessels/nerve/tissue from outside the donated graft used in the transplant procedure
	Clinical Information: Transplant Procedure	Surgical Procedure	Display Only - Cascades from Removal Worksheet
	Clinical Information: Transplant Procedure - Preservation Information	Warm Ischemia Time (include anastomotic time)
	Clinical Information: Transplant Procedure - Preservation Information	Cold Ischemia Time
	Clinical Information: Post Transplant	Graft Status
	Clinical Information: Post Transplant	Date of Graft Failure
	Clinical Information: Post Transplant - Causes of Graft Failure	Thrombosis
	Clinical Information: Post Transplant - Causes of Graft Failure	Acute Rejection
	Clinical Information: Post Transplant - Causes of Graft Failure	Acute Rejection - Banff score
	Clinical Information: Post Transplant - Causes of Graft Failure	Acute Rejection - Visual skin changes
	Clinical Information: Post Transplant - Causes of Graft Failure	Chronic Rejection
	Clinical Information: Post Transplant - Causes of Graft Failure	Chronic Rejection - Visual skin changes
	Clinical Information: Post Transplant - Causes of Graft Failure	Ischemia
	Clinical Information: Post Transplant - Causes of Graft Failure	Sepsis / Infection
	Clinical Information: Post Transplant - Causes of Graft Failure	Trauma
	Clinical Information: Post Transplant - Causes of Graft Failure	Patient requested removal
	Clinical Information: Post Transplant - Causes of Graft Failure	Non-compliance: immunosuppression
	Clinical Information: Post Transplant - Causes of Graft Failure	Non-compliance: rehabilitation
	Clinical Information: Post Transplant - Causes of Graft Failure	Non-compliance: level of activity
	Clinical Information: Post Transplant - Causes of Graft Failure	Other
	Clinical Information: Post Transplant - Causes of Graft Failure	Other - Other Specify
	Clinical Information: Post Transplant - Discharge Lab Data	Serum Creatinine (mg/dL)
	Clinical Information: Post Transplant - Discharge Lab Data	Hemoglobin A1c (%)
	Clinical Information: Post Transplant - Major Transplant Complication	Arterial Thrombosis
	Clinical Information: Post Transplant - Major Transplant Complication	Venous Thrombosis
	Clinical Information: Post Transplant - Major Transplant Complication	More than 5 pRBC (packed red blood cells) units
	Clinical Information: Post Transplant - Major Transplant Complication	Cardiac arrest
	Clinical Information: Post Transplant - Major Transplant Complication	DIC (Disseminated intravascular coagulation)
	Clinical Information: Post Transplant - Major Transplant Complication	Graft/reperfusion syndrome
	Clinical Information: Post Transplant - Major Transplant Complication	Other Major Transplant Complications
	Clinical Information: Post Transplant - Major Transplant Complication	Other Major Transplant Complications - Other Specify
	Clinical Information: Post Transplant	Did patient have any acute rejection episodes between transplant and discharge
	Clinical Information: Post Transplant	Did patient have any acute rejection episodes between transplant and discharge - Number of episodes
	Clinical Information: Post Transplant	{For each episode} Date of acute rejection diagnosis
	Clinical Information: Post Transplant	{For each episode} Acute rejection was treated
	Clinical Information: Post Transplant	{For each episode} Visual skin changes
	Clinical Information: Post Transplant	{For each episode} Biopsy was done to confirm acute rejection
	Clinical Information: Post Transplant	{For each episode} Banff Score
	Treatment	Antiviral Prophylaxis
	Treatment	Antibacterial Prophylaxis
	Treatment	Antifungal Prophylaxis
	Treatment	Peri-operative anticoagulation
	Topical Immunosuppressive Medications	Immunosuppression medications
	Topical Immunosuppressive Medications	Immunosuppression medications - Other Specify
	Topical Immunosuppressive Medications	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	Induction indication
	Non-Topical Immunosuppressive Medications	Number of days of induction
	Non-Topical Immunosuppressive Medications	Maintenance indication
	Non-Topical Immunosuppressive Medications	Anti-rejection indication
		Public Burden Statement