Donor Height Centimeters Inches Missing Reason: Not Done Unknown. Donor Weight Kilograms Pounds Missing Reason: Not Done Unknown. Female Male Unknown
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1 Page 1 of 6 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form 2: Donor Toggle Question Year/Info Print this Form t Started Transplant Date 1 Donor Age Indicate age in months, days, or years Days Months Years 2 Donor Date of Birth Height and Weight 3 Donor Height Centimeters Inches t Done Calculated BSA: n/a BMI: n/a 4 Donor Weight Kilograms Pounds t Done 5 Donor Sex Female Male 6 Donor Race Check all that apply. American Indian or Alaskan Native Asian Black Pacific Islander White
2 Page 2 of 6 7 Hispanic or Latino if of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture of origin, regardless of race. 8a Donor Date of Death MM/DD/YYYY 8b Donor Cause of Death Check only one. Anoxia Cerebrovascular/Stroke CNS Tumor Head Trauma 8c Donor Mechanism of death Check only one. Asphyxiation Blunt Injury Cardiovascular Cerebral Embolism CNS Infection Drowning Drug Intoxication Electrical Gunshot Wound Intracranial Hemorrhage (ICH) Seizure Stab Sudden Infant Death 8d Donor Circumstances of death Alleged Child Abuse Alleged Homicide Alleged Suicide Motor Vehicle Accident n-motor Vehicle Accident 9 Donor Downtime Previously called "Duration of Cardiac Arrest".
3 Page 3 of 6 9a Duration of Donor Downtime Previously called "Duration of Cardiac Arrest". Enter duration in minutes. 10 Chest Compressions (CPR) 10a If yes, CPR Time Enter duration in minutes minutes 11 Donor Blood Type A AB B O 11a Blood type A subtype A1 A2 12 Donor Rh Negative Positive 13 Donor Past Medical History Check all that are known. Cancer at time of procurement Diabetes History of Cancer Hypertension Infection, specify Mitral Valve Prolapse ne 13a If donor had diabetes, was patient on insulin? 13 Cancer at Time of Procurement, Location
4 Page 4 of 6 13 Cancer Type/Location 14 Did the donor have an increased risk for HIV, HBV, HCV? 14a If yes, specify increased risk. At risk medical history (i.e. hemodialysis, new diagnosis of or treatment for STD in past 12 months) At risk social history (specify) Hemodiluted sample 14a.i If at risk social history, specify. Check all that apply Incarceration Injected Drug Use Mother with HIV Sexual exposure Pre-transplant Donor Echocardiogram 15 Pre-Transplant Donor Echocardiogram (closest to time of procurement) 15a Result of Donor Echocardiogram Abnormal rmal 15a.i If abnormal, please specify Check all that apply. Abnormal Septal Motion Diffuse Wall Motion Abnormality Focal Wall Motion Abnormality Mitral Regurgitation Tricuspid Regurgitation 15b Donor Fractional Shortening t Done
5 Page 5 of 6 Donor Estimated LV Eject 15c Fraction t Done Pre-transplant Donor Angiogram 16 Pre-transplant Donor Angiogram 16a Angiogram results Abnormal, Specify rmal Donor Serologies 17a 17b 17c 17d 17e 17f 17g 17h 17i HIV Serology AIDS testing CMV IgG Cytomegalovirus testing IFA Toxo Toxoplasma testing EBV IgG Epstein Barr Virus RPR/Syphilis Syphillis testing HBs Ag Hepatitis B surface antigen HB core Ab Hepatitis B core antibody HBs Ab Hepatitis B surface antibody Hep C ab Hepatitis C antibody
6 Page 6 of 6 Donor on Inotropes, Pressors, or Thyroid Hormones at time of recovery/harvest? 18a Tri-iodothyronine (Thyroid hormone) T3 18b 18c 18d 18e 18f 18g 18h 18i T4 Levothyroxine (Thyroid hormone) Epinephrine Adrenaline (Inotrope, pressor) Dopamine (Inotrope) Dobutamine Dobutrex (Inotrope) Vasopressin Pitressin (Pituitary hormone) Levophed repinephrine (Inotrope, Pressor) Milrinone Primacor (Inotrope) Neosynephrine Phenylephrine (Pressor) 18j 18j Please specify Other 2018 PHTS [PHTS]
Months Years. Centimeters Inches Missing Reason: Not Done Unknown. Kilograms Pounds Missing Reason: Not Done Unknown. Female Male Unknown
Form 2: Donor Print this Form t Started 1 2 Transplant Date Donor Age Indicate age in months, days, or years Days Months Years Donor Date of Birth Height and Weight 3 Donor Height Centimeters Inches t
Form 8: Post Transplant Annual Followup
Page 1 of 8 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form 8: Post Transplant Annual Followup Toggle Question Year/Info Print this Form t Started
4a.i. 4a.ii. Form 12: Pre Transplant Status Report. Height and Weight. Status.
PHTS - Form : Pre Transplant Report Page of 5 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form : Pre Transplant Report Print this Form t Started Was
Form 4: Coronary Evaluation
Page of 8 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form : Coronary Evaluation Toggle Question Year/Info Print this Form t Started Date of Coronary
Form 8: Post Transplant Annual Followup
Page 1 of 7 Show trials/registries Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form 8: Post Transplant Annual Followup Print this Form t Started 1
Anoxic insult Stroke/Cerebrovascular accident
Page 1 of 5 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form 10: Death Print this Form t Started 1 Date of Death MM/DD/YYYY 2 Primary cause of death
Form 4: Coronary Evaluation
Page of 7 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved Form : Coronary Evaluation Print this Form t Started Date of Coronary Evaluation Coronary Evaluation
Hepatitis Case Investigation
* indicates required fields Does patient also have: Hepatitis Case Investigation West Virginia Electronic Disease Surveillance System Division of Surveillance and Disease Control Infectious Disease Epidemiology
4 Has this patient been transplanted No
Form 1RL: Relisting Print this Form t Started 1 Date of Relisting Height and Weight 2 Height Centimeters Inches Calculated BSA: n/a BMI: n/a 3 Weight Kilograms Pounds 4 Has this patient been transplanted
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Height Centimeters Inches Missing Reason: Not Done Unknown
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