Transplant Candidate Registration Form (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Submitting this paper form does not add your patient to the waiting list. Page 1 of 2 Provider Information Organ Registered: Kidney

Date placed on list: Provider Number UNOS Center Code Center Name Candidate Information

Name: Previous Surname: Last First MI DOB: SSN: HIC: Gender: Male Female State of Permanent Residence: Permanent Zip Code: Waiting Zip Code:

Employment Status (Select one) (Working = Employed, Home, School) Ethnicity Hispanic/Latino Non-Hispanic/Non-Latino Working Full Time Race Working Part Time By Choice White Native Hawaiian or Working Part Time Due to Disease Black or African American other Pacific Islander Working Part Time, Reason Unknown American Indian or Alaskan Mid-East or Arabian Not Working By Choice Native Indian Sub-Continent Not Working Due to Disease Asian Not Working, Unable to Find Employment Not Working, Reason Unknown Citizenship (Select one) Retired U.S. Citizen Resident Alien Employment Status Unknown Non-Resident Alien Patient Less Than Five Years Old Home country: Previous Transplants Highest Education Level (Select one) Yes No None Associate/Bachelor If Yes, give the number of previous transplants for each organ type and Grade School (0-8) Degree latest transplant date. High School (9-12) Post-College Graduate Number Date Attended College/Technical Degree Kidney School Unknown Liver Pancreas (whole) Medical Condition (Select one) Pancreas (islet cells) Patient in Intensive Care Unit Heart Hospitalized, but not in Intensive Care Unit Lung Not hospitalized Intestine Patient on Life Support Bone Marrow (Please provide for all patients regardless of medical status) Source of Payment Yes No (Check Yes, No or Unknown for each secondary source of payment) (Check applicable) Primary (Largest %, Select one) Secondary ECMO IABP PGE IV Inotropes Medicare Y NU Ventilator Other mechanism Medicaid Y NU Specify: US/State Government Agency Y NU VAD Brands Private Insurance Y NU Cardio West Thoratec HMO/PPO Y NU Abiomed Other VAD, specify: Self Y NU Novacor Donation Y NU Heartmate Free Care Y NU Functional Status (Select one) (How does patient perform daily activities?) Dept. of Veterans Affairs Pending No activity limitations. (NYHA Class I or Class II) Foreign Govt., Specify: Performs activities of daily living with some assistance. (NYHA Class III) Performs activities of daily living with total assistance. (NYHA Class IV) N/A Patient hospitalized Unknown

UNOS/PHS/HCFA 3/29/01 Transplant Candidate Registration Form FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Name: Page 2 of 2 Clinical Information Height ft. in. OR cm Weight lbs. OR kg

ABO Blood Group: Rh:

Primary Diagnosis (Use codes) If other, specify:

General Medical Factors Diabetes No Diabetes Insulin Dependent Diabetes Non-Insulin Dependent Diabetes Diabetes, Dependency Unknown Unknown Dialysis No Dialysis Hemodialysis Peritoneal Dialysis

Peptic Ulcer Disease No Yes, Drug Treated Yes, Not Drug Treated Yes, Drug Treatment Unknown Unknown Angina/Coronary Artery Disease No Angina, Unstable Angina, Stable Angina, Stability Unknown Unknown Drug Treated Systemic Hypertension Y NU Symptomatic Cerebrovascular Disease Y NU Symptomatic Peripheral Vascular Disease Y NU Drug Treated COPD Y NU Pulmonary Embolism (within last 6 months) Y NU Any Previous Transfusions Y NU Any Previous Malignancy Y NU (Exclude non-melanoma skin cancer) PRA > 10% (with DTT or DTE testing) Y NU Most recent absolute Creatinine mg/dl Total Serum Albumin g/dl

Kidney Medical Factors Exhausted vascular access Y NU Exhausted peritoneal access Y NU Age of diabetes onset yrs Creatinine clearance ml/min Creatinine clearance method: Isotope Calculated Measured Standard

UNOS/PHS/HCFA 1/28/00

Person completing form: Date completed: Kidney Transplant Recipient Registration Form (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 2 Provider Information

Provider Number Center Code Transplant Center Name Surgeon Name UPIN Number Recipient Information

Name: Transplant Date: Last First MI DOB: SSN: HIC: Gender: Male Female

Patient Status Donor Information Donor Type: Primary Diagnosis Specify: (Use code) UNOS Donor ID Donor Name: Last First

Patient Status Source of Payment (Check Yes, No or Unk for each secondary source) Date: of Report or Death Primary (Largest %, Select one) Secondary Living Medicare Y NU Dead Cause of Death: Medicaid Y NU (Use code) Specify: US/State Government Agency Y NU Retransplanted prior to hospital discharge Private Insurance Y NU HMO/PPO Y NU Transplant Hospitalization Self Y NU Date of discharge from transplant center: Donation Y NU Date of admission to transplant center: Free Care Y NU Was patient transferred from another hospital prior to transplant? Dept. of Veterans Affairs Foreign Gov’t. Specify: Yes No If Yes, date of admission to transferring hospital:

Medical Condition at Time of Transplant (Select one) Pretransplant Clinical Information Patient in Intensive Care Unit Previous Kidney Transplants Yes No Hospitalized, but not in Intensive Care Unit If Yes, number of previous kidney transplants: Not hospitalized Previous Tx Transplant Date Graft Failure Date Patient on Life Support Yes No Most recent (Please provide for all patients regardless of medical status) 2nd most recent 3rd most recent Functional Status (How does the patient perform activities of daily living? Select one) Pretransplant Dialysis No activity limitations. (NYHA Class I or Class II) None Hemodialysis Peritoneal dialysis Performs activities of daily living with some assistance. If Yes, date first dialyzed: (NYHA Class III) Average daily insulin: units Performs activities of daily living with total assistance. Serum Creatinine at time of transplant: mg/dl (NYHA Class IV) Creatinine clearance: ml/min N/A Patient hospitalized Creatinine clearance method: Unknown Isotope Calculated Measured standard Employment Status (Select one) (Working = Employed, Home, School) Pretransplant Serology Working Full Time HIV Screening P N U ND I C Confirmation P N U ND I C Working Part Time By Choice CMV IgG P N U ND I C Working Part Time Due to Disease IgM P N U ND I C Working Part Time, Reason Unknown DNA P N U ND I C Not Working By Choice Hepatitis B Core Antibody P N U ND I C Surface Antigen P N U ND I C Not Working Due to Disease HBV DNA P N U ND I C Not Working, Unable to Find Employment Hepatitis C Antibody Screen P N U ND I C Not Working, Reason Unknown RIBA Test P N U ND I C Retired HCV RNA P N U ND I C Epstein Barr Virus IgG P N U ND I C Employment Status Unknown IgM P N U ND I C Patient Less Than Five Years Old DNA P N U ND I C

UNOS/PHS/HCFA 5/18/01 Kidney Transplant Recipient Registration Form FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Name: Page 2 of 2

Biopsy of Donor Kidney at Transplant Center Most recent Serum Creatinine prior to discharge: mg/dl No biopsy done Frozen Left Kidney Did kidney produce > 40 ml of urine in the Y N Permanent Left Kidney first 24 hours? Frozen Right Kidney Did patient need dialysis within first week? Y N Permanent Right Kidney Did Creatinine decline by 25% or more in first Y N Frozen En-bloc Kidney 24 hours on 2 separate serum samples taken Permanent En-bloc Kidney within the first 24 hours?

Kidney Results: Rejection Information Glomerulosclerosis % Fibrosis Arteriolosclerosis Patient treated for rejection? Y N 0-5 None None If Yes, biopsy done? Y N 6-10 Mild Mild If Yes, rejection confirmed? Y N 11-15 Moderate Moderate 16-20 Large Large BANFF Level: Y N > 20 Stages: 1A 1B 2 3

Pretransplant Blood Transfusions: Height ft. in. OR cm 0 1-5 6-10 >10 Unk Weight lbs. OR kg Date of last transfusion: Donor specific transfusions? Yes No Unk Treatment Number of previous pregnancies: Immunosuppressive Information 0 1 2 3 4 5 >5 Unk Are any medications given currently for Y N maintenance or anti-rejection: Any known malignancies since listing: Yes No Unk Did the patient participate in any clinical Y N Transplant Clinical Information research protocol for immunosuppressive medications: If Yes, specify: Multiple Organ Recipient: Other Therapy Procedure Type: Photopheresis Y N Plasmapheresis Y N Preservation Information Total Cold Ischemic Time: hrs Total Lymphoid Irradiation (TLI) Y N Anastomotic Time: min Biologicals/Vaccines Warm Ischemic Time: min Total Pump Time: hrs min Cytogam (CMV) Y N Gamimune N 10% Y N Number of blood transfusions at time of transplant: Gammagard SD Y N Post Transplant Clinical Information Acyclovir (Zovirax) Y N Ganciclovir (Cytovene) Y N Graft Status: Functioning Failed HBIG (Hepatitis B Immume Globulin) Y N Resumed maintenance dialysis: Yes No Flu Vaccine (Influenza virus) Y N If Yes, date resumed: Dialysis center provider #: Other: Dialysis center name: Other: If failed, date of graft failure: Cause of graft failure (Check Yes, No or Unknown for each contributory cause of graft failure) Primary (Check one) Contributory Hyperacute rejection Acute rejection Y NU Primary failure Graft thrombosis Y NU Infection Y NU Surgical complications Y NU Urological complications Y NU Recurrent disease Y NU Other: Other:

UNOS/PHS/HCFA 3/29/01

Person completing form: Date completed: Immunosuppression Treatment (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 1 Recipient Information

Name: Last First MI

Provider Number Center Code Tx Center Name Donor Information

UNOS Donor ID Donor Name: Last First

Immunosuppression Therapy Induct Days Maint Anti-rej STEROIDS Prednisone (Deltasone, Orasone) Methylprednisolone (Solu-medrol, Medrol, A-Methapred) T-CELL ACTIVATION INHIBITORS Cyclosporin A (CSA, Sandimmune, CyA, CyS) Neoral (CyA-NOF) FK506 (Prograf, Tacrolimus) Deoxyspergualin (DSG, 15-DSG, Gusperimus, Spanidin) Rapamycin (RAPA, Sirolimus, Rapamune) Gengraf (Abbot CyA) Certican (RAD, Enverolimus) ANTIMETABOLITES Azathioprine (AZA, Imuran) Mycophenolate Mofetil (MMF, Cellcept, RS61443) Cytoxan (Cyclophosphamide) Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) Brequinar Sodium (BRQ) Leflunomide (LFL) Mizoribine (Bredinin) ANTI-LYMPHOCYTE RECEPTOR ANTIBODIES T10B9 (Medimmune) ATG (Atgam, Anti-thymocyte Globulin)/NRATG/NRATS OKT3 (Orthoclone, Muromonab) Thymoglobulin Zenapax Simulect DAB486 - IL - 2 Anti - ICAM - 1 CYTOKINE INHIBITORS IL - 1 Receptor Antagonist Anti - IL - 6

OTHER IMMUNOSUPPRESSIVE MEDICATION Other: Other:

UNOS/PHS/HCFA 11/30/00

Person completing form: Date completed: Cadaver Donor Registration Form (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 4 Provider Information

OPO Provider Number Center Code OPO Center Name Donor Hospital Provider Number Donor Hospital Name

Date of Referral call: Recovered outside U.S: Y N If Yes, country:

Donor Information UNOS Donor ID: Name: DOB: If Unknown, give age: Last First Gender: Male Female Home City: State: Home Zip Code:

Ethnicity Hispanic/Latino Non-Hispanic/Non-Latino Was Death reported to Medical Examiner/Coroner: No Race Medical examiner consented White Native Hawaiian or Medical examiner refused consent Black or African American other Pacific Islander Unknown American Indian or Alaska Mid-East or Arabian Was the donor’s wish to donate organs Y NU Native Indian Sub-Continent known to the family prior to donation request: Asian Was a formal organ donation request made: (Select one) Citizenship (Select one) No U.S. Citizen Resident Alien Yes, family initiated Non-Resident Alien, specify country Approached by physican Home country: Approached by nurse Approached by clergy Approached by OPO Coordinator Cause of Death(Select one) Approached by Social Worker Anoxia/Cardiac Arrest Head Trauma Other, Specify: Cerebrovascular/Stroke CNS Tumor Written consent for organ donation obtained by: (Select one) Other, specify: No consent obtained Physician Mechanism of Death(Select one) OPO Coordinator Nurse Drowning Stab Social Worker Clergy Seizure Blunt Injury Other, specify: Drug Intoxication Sudden Infant Death Was the consent based solely on Y N Asphyxiation Intracranial Hemorrhage written documentation of the patient? Cardiovascular /Stroke If Yes, indicate mechanisms: Electrical Death from Natural Driver’s license Living will Gunshot Wound Causes Donor card Attorney in fact None of the Above Donor registry Other, specify: Circumstances of Death(Select one) Motor Vehicle Accident Death from Natural Alleged Suicide Causes Consent Information Alleged Homicide None of the Above Tissue Requested Y N Alleged Child Abuse If no, reason code: Non-Motor Vehicle Accident Other, Specify: Procurement and Consent Tissue Consented Y N If no, reason code: Was donor suitable for procurement of organs: Y N Other, Specify: If No, select one primary reason: HIV + Medical History Clinical Information HCV + Social History ABO Blood Hepatitis B + Cancer Group: Rh: Tuberculosis Age Brain death criteria not met Height ft. in. OR cm Other, specify: Weight lbs. OR kg

UNOS/PHS/HCFA 1/28/00

Person completing form: Date completed: Cadaver Donor Registration Form FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Name: Page 2 of 4

Terminal Lab Data(U=Unknown, ND=Not Done ) Clinical Infection: Y NU Serum Creatinine mg/dl Source Confirmed by Culture BUN mg/dl Blood Y N Total Bilirubin mg/dl Lung Y N SGOT/AST u/ml Urine Y N SGPT/ALT u/ml Other, specify: Y N Protein in urine Y NU Last Serum sodium prior to procurement Y NU > 170 mEq/l: Heart Donor’s Cardiac Function Pancreas: (PA donors only) History of previous MI: Y N Serum Lipase u/L LV ejection fraction: % Serum Amylase u/L Method: Echo Medications given to donor (24 hours prior to cross clamp) MUGA Anticonvulsants Y NU Angiogram Antihypertensives Y NU If LV ejection fraction < 50%: Vasodilators Y NU Segmental abnormalities Y N Dopamine Y NU Global abnormalities Y N Dobutamine Y NU Coronary angiogram: Y N DDAVP Y NU If Yes, normal: Y N Other, specify: If abnormal, number of vessels with 1 2 3 Other, specify: > 50% stenosis: Other, specify: Inotropic support: Y N If Yes, list the agents used at acceptance and at time of Serology procurement: Anti-HIV I P N U ND I C At Acceptance: Anti-HIV II P N U ND I C Agent Dosage Time Started Anti-HTVL I P N U ND I C (mg/kg/min) (military time) Anti-HTVL II P N U ND I C 1 RPR-VDRL P N U ND I C 2 Anti-CMV P N U ND I C 3 HBsAg P N U ND I C 4 Anti-HBC P N U ND I C Anti-HCV P N U ND I C

Donor Management (Pretreatment medications given after brain death At Time of Procurement: declared and 24 hours prior to procurement) Agent Dosage Time Started Did donor receive prerecovery medication: Y NU (mg/kg/min) (military time) If Yes, check Yes, No or Unknown for each of the following: 1 2 Steriods Y NU 3 Diuretics Y NU 4 T3 Y NU T4 Y NU Other, specify: Right heart catheterization: Y N Other, specify: If Yes: Other, specify: CVP PCW Pressure Other, specify: PA Systolic CO Transfusion units prior to surgery:(This hospitalization) PA Diastolic 0 1-5 6-10 >10 Unk Biopsy Performed: Transfusion units intraoperatively: No Biopsy 0 1-5 6-10 >10 Unk Yes, Myocarditis Three or more inotropic agents at time Y N Yes, Negative Biopsy Result of incision: Yes, Other Diagnosis, Specify Cardiac arrest since neurological event Y N Specify: that lead to declaration of brain death: If Yes, duration of resuscitation: min

UNOS/PHS/HCFA 1/28/00

Person completing form: Date completed: Cadaver Donor Registration Form FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Name: Page 3 of 4 Donor History Lifestyle Factors: Chemical Use: History of prison Y NU Cigarette Use (> 20 pack years) -Ever Y NU Tattoos Y NU AND continued in last six months Y NU Sexual promiscuity Y NU Alcohol Dependency -Ever Y NU Other: AND continued in last six months Y NU Other: IV Drug Use -Ever Y NU Other: AND continued in last six months Y NU Cocaine Use -Ever Y NU Organ Recovery AND continued in last six months Y NU Recovery Date(donor to OR): Other Drug Use -Ever Y NU AND continued in last six months Y NU Non-Heart beating donor: Y N If Yes, controlled: Y NU History of Diabetes: Y NU If Yes, core cooling used: Y NU If Yes, duration: If Yes, estimated warm ischemic time: min 0-5 Years 6-10 Years >10 Years Unk Clamp date: Insulin Dependent: Y N If Yes, how long: Clamp time (Military time): Time zone: 0-5 Years 6-10 Years >10 Years Unk Left Kidney Biopsy: Right Kidney Biopsy: History of Hypertension: Y NU Y N Y N If Yes, duration: Glomerulosclerosis % Glomerulosclerosis % 0-5 Years 6-10 Years >10 Years Unk 0-5 0-5 If Yes, method of control: 6-10 6-10 Diet Y NU 11-15 11-15 Diuretics Y NU 16-20 16-20 Other Hypertensive Medication Y NU > 20 > 20 Pump: Y N Pump: Y N History of Cancer: Y NU Flow rate: ccs/min Flow rate: ccs/min If Yes, cancer free interval years. Perfusion pressure Systolic: Perfusion pressure Systolic: If Yes, Primary site: (Select one) mm/Hg mm/Hg Skin Perfusion pressure Diastolic:Perfusion pressure Diastolic: Squamous, basal cell Melanoma mm/Hg mm/Hg CNS Tumor Astrocytoma Meningioma Liver biopsy: Y N Glioblastoma multiforme Intracranial surgery % Fatty: Medulloblastoma Intracranial no surgery 0-19 20-35 > 35 Neuroblastoma CNS Other Portal infiltrates: Y N Angioblastoma Fibrosis: Y N Genitourinary Pump Y N Bladder Ovarian Flow rate: ccs/min Uterine Cervix Penis, Testicular Perfusion pressure Systolic: mm/Hg Uterine body Endometrial Prostate Perfusion pressure Diastolic: mm/Hg Uterine body Kidney Choriocarcinoma Unknown genitourinary Lung: Vulva pO2on 100%: Gastrointestinal Left Lung: Esophageal Colo-rectal Bronchoscopic abnormalities: Y N Stomach Liver & biliary tract Small Intestine Pancreas If Yes, purulent drainage: Y N Breast Chest X-ray abnormalities: Y N Thyroid If Yes, Infiltrate: Y N Tongue/Throat If Yes: Upper Mid Lower Larynx Lung (include bronchial) Right Lung: Leukemia/Lymphoma Bronchoscopic abnormalities: Y N Other, specify: If Yes, purulent drainage: Y N Cancer at procurement Chest X-ray abnormalities: Y N Intracranial Y NU Extracranial Y NU If Yes, Infiltrate: Y N Skin Y NU If Yes: Upper Mid Lower

UNOS/PHS/HCFA 1/28/00

Person completing form: Date completed: Cadaver Donor Registration Form FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Name: Page 4 of 4 Kidney Right - Liver Segment 2 - Reason Code: Other Specify: Reason Code: Other Specify: Discard Code: Other Specify: Discard Code: Other Specify: Recov. Team # Placed by: Type Share: Recov. Team # Placed by: Type Share: Flush Solution: Other Specify: Flush Solution: Other Specify: Storage Solution: Other Specify: Storage Solution: Other Specify:

Recipient Name SSN Provider # - Center Code - Tx Center Name Recipient Name SSN Provider # - Center Code - Tx Center Name Kidney Left - Intestine - Reason Code: Other Specify: Reason Code: Other Specify: Discard Code: Other Specify: Discard Code: Other Specify: Recov. Team # Placed by: Type Share: Recov. Team # Placed by: Type Share: Flush Solution: Other Specify: Flush Solution: Other Specify: Storage Solution: Other Specify: Storage Solution: Other Specify:

Recipient Name SSN Provider # - Center Code - Tx Center Name Recipient Name SSN Provider # - Center Code - Tx Center Name Kidney Double/Enbloc - Intestine Segment 1- Reason Code: Other Specify: Reason Code: Other Specify: Discard Code: Other Specify: Discard Code: Other Specify: Recov. Team # Placed by: Type Share: Recov. Team # Placed by: Type Share: Flush Solution: Other Specify: Flush Solution: Other Specify: Storage Solution: Other Specify: Storage Solution: Other Specify:

Recipient Name SSN Provider # - Center Code - Tx Center Name Recipient Name SSN Provider # - Center Code - Tx Center Name Pancreas - Intestine Segment 2 - Reason Code: Other Specify: Reason Code: Other Specify: Discard Code: Other Specify: Discard Code: Other Specify: Recov. Team # Placed by: Type Share: Recov. Team # Placed by: Type Share: Flush Solution: Other Specify: Flush Solution: Other Specify: Storage Solution: Other Specify: Storage Solution: Other Specify:

Recipient Name SSN Provider # - Center Code - Tx Center Name Recipient Name SSN Provider # - Center Code - Tx Center Name Pancreas Segment 1 - Heart - Reason Code: Other Specify: Reason Code: Other Specify: Discard Code: Other Specify: Discard Code: Other Specify: Recov. Team # Placed by: Type Share: Recov. Team # Placed by: Type Share: Flush Solution: Other Specify: Flush Solution: Other Specify: Storage Solution: Other Specify: Storage Solution: Other Specify:

Recipient Name SSN Provider # - Center Code - Tx Center Name Recipient Name SSN Provider # - Center Code - Tx Center Name Pancreas Segment 2 - Lung Right - Reason Code: Other Specify: Reason Code: Other Specify: Discard Code: Other Specify: Discard Code: Other Specify: Recov. Team # Placed by: Type Share: Recov. Team # Placed by: Type Share: Flush Solution: Other Specify: Flush Solution: Other Specify: Storage Solution: Other Specify: Storage Solution: Other Specify:

Recipient Name SSN Provider # - Center Code - Tx Center Name Recipient Name SSN Provider # - Center Code - Tx Center Name Liver - Lung Left - Reason Code: Other Specify: Reason Code: Other Specify: Discard Code: Other Specify: Discard Code: Other Specify: Recov. Team # Placed by: Type Share: Recov. Team # Placed by: Type Share: Flush Solution: Other Specify: Flush Solution: Other Specify: Storage Solution: Other Specify: Storage Solution: Other Specify:

Recipient Name SSN Provider # - Center Code - Tx Center Name Recipient Name SSN Provider # - Center Code - Tx Center Name Liver Segment 1 - Lung Double/En-bloc - Reason Code: Other Specify: Reason Code: Other Specify: Discard Code: Other Specify: Discard Code: Other Specify: Recov. Team # Placed by: Type Share: Recov. Team # Placed by: Type Share: Flush Solution: Other Specify: Flush Solution: Other Specify: Storage Solution: Other Specify: Storage Solution: Other Specify:

Recipient Name SSN Provider # - Center Code - Tx Center Name Recipient Name SSN Provider # - Center Code - Tx Center Name

UNOS/PHS/HCFA 1/28/00

Person completing form: Date completed: Cadaver Donor Referral Form (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 1 Provider Information Date of Referral call:

OPO Provider Number Center Code OPO Center Name Donor Hospital Provider Number Donor Hospital Name

Donor Information UNOS Donor ID: Name: DOB: If Unknown, give age: Last First Gender: Male Female Home City: State: Home Zip Code:

Ethnicity Hispanic/Latino Non-Hispanic/Non-Latino Was Death reported to Medical Examiner/Coroner: No Race Medical examiner consented White Native Hawaiian or Medical examiner refused consent Black or African American other Pacific Islander Unknown American Indian or Alaska Mid-East or Arabian Was the donor’s wish to donate organs Y NU Native Indian Sub-Continent known to the family prior to donation request: Asian Unknown Was a formal organ donation request made: (Select one) No Citizenship (Select one) Yes, family initiated U.S. Citizen Resident Alien Approached by physican Non-Resident Alien, specify country Approached by nurse Home country: Approached by clergy Unknown Approached by OPO Coordinator Cause of Death(Select one) Approached by Social Worker Anoxia/Cardiac Arrest Head Trauma Other, Specify: Cerebrovascular/Stroke CNS Tumor Written consent for organ donation obtained by: (Select one) Other, specify: No consent obtained Physician OPO Coordinator Nurse Mechanism of Death(Select one) Social Worker Clergy Drowning Stab Other, specify: Seizure Blunt Injury Was the consent based solely on Y N Drug Intoxication Sudden Infant Death written documentation of the patient? Asphyxiation Intracranial Hemorrhage If Yes, indicate mechanisms: Cardiovascular /Stroke Driver’s license Living will Electrical Death from Natural Donor card Attorney in fact Gunshot Wound Causes Donor registry None of the Above Other, specify:

Circumstances of Death(Select one) Motor Vehicle Accident Death from Natural Alleged Suicide Causes Alleged Homicide None of the Above Alleged Child Abuse Non-Motor Vehicle Accident Procurement and Consent Was donor suitable for procurement of organs: Y N If No, select one primary reason: HIV + Medical History HCV + Social History Hepatitis B + Cancer Tuberculosis Age Brain death criteria not met Other, specify:

UNOS/PHS/HCFA 1/28/00

Person completing form: Date completed: Living Donor Registration (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 1 Provider Information

Provider Number Center Code Recipient Transplant Center Name

Donor Information Donor ID: Name: Transplant Date: Last First DOB: SSN: Gender: Male Female Blood Type: Rh: Home City: Home State: Home Zip Code: Living Donor Type: (Indicate the relationship of the donor to the Clinical Information recipient by checking one.) Height ft. in. OR cm Living, Biologically Related Weight Parent lbs. OR kg Child Serology Identical Twin HIV Screening P N U ND I C Full Sibling (Not Identical Twin) Confirmation P N U ND I C Half Sibling CMV IgG P N U ND I C Other Relative, specify: IgM P N U ND I C Living, Biologically Unrelated DNA P N U ND I C Spouse Hepatitis B Core Antibody P N U ND I C Other, specify: Surface Antigen P N U ND I C HBV DNA P N U ND I C Ethnicity Hispanic/Latino Non-Hispanic/Non-Latino Hepatitis C Antibody Screen P N U ND I C RIBA Test P N U ND I C Race HCV RNA P N U ND I C White Native Hawaiian or Epstein Barr Virus IgG P N U ND I C Black or African American other Pacific Islander IgM P N U ND I C American Indian or Alaska Mid-East or Arabian DNA P N U ND I C Native Indian Sub-Continent Asian Creatinine: (Kidney donors) Preoperative: mg/dl Citizenship (Select one) At Discharge: mg/dl U.S. Citizen Resident Alien Kidney Procedure Type: Non-Resident Alien, specify country Transabdominal Home country: Laparoscopic Flank

Highest Education Level (Select one) Blood Pressure (mmHg) None Associate/Bachelor Systolic Preoperative: Systolic at Discharge: Grade School (0-8) Degree Diastolic Preoperative: Diastolic at Discharge: High School (9-12) Post-College Graduate Attended College/Technical Degree Length of hospital stay: days School Unknown Bleeding requiring transfusion: 0 1-5 6-10 >10 Unk Source of Payment Y N (Check Yes, No or Unknown for each secondary source of payment) Infections during hospitalization: Y N Primary (Largest %, Select one) Secondary Pulmonary Embolism during hospitalization: Return to OR after recovery of donor organ: Y N Medicare Y NU Date of Death: Medicaid Y NU Cause of Death: Donation Related Other Cause US/State Government Agency Y NU Organ Recovery Organ Recovery Date: Private Insurance Y NU Recovered outside the U.S: Y N HMO/PPO Y NU Specify Country: Self Y NU

Donation Y NU Donor Recovery Facility Free Care Y NU Donor Workup Facility Dept. of Veterans Affairs

Pending Organ(s) Recovered Recipient Name: Last First

Foreign Govt. Specify: Recipient SSN

UNOS/PHS/HCFA 3/22/01

Person completing form: Date completed: Living Donor Follow-Up (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 1 Provider Information

Tx Provider Number Center Code Tx Center Name

Follow-up Number Center Code Follow-up Center Name Donor Information

Name: Donor ID: Last First Recovery Date: DOB: SSN: Gender: Male Female

Patient Status Date: of Report, Last Seen or Death Living Dead Lost to Follow-Up

Cause of Death: Donation Related Other Cause Clincial Information Height ft. in. OR cm Weight lbs. OR kg

Blood Pressure at Follow-Up: Diastolic: mmHg Systolic: mmHg

Treatment of Kidney Donor Related Complications Serum Creatinine: mg/dl Complications: Antihypertensive Drugs (specify)

Any Non-maintenance Dialysis Maintenance Dialysis Added to UNOS kidney transplant candidate waiting list

Liver Donor Bilirubin: mg/dl AST: U/ml Alkaline Phosphate: units/L Complications: Bile Leak Hepatic Resection Abscess Liver Failure Added to UNOS liver transplant candidate waiting list

Number of hospitalizations during follow-up period: Most recent diagnosis: Second most recent diagnosis: Third most recent diagnosis:

UNOS/PHS/HCFA 1/28/00

Person completing form: Date completed: Donor Histocompatibility Form (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 1 Provider Information

OPO Provider Number Center Code OPO Center Name

Lab Provider Number Center Code Lab Name Donor Information

Donor Type: UNOS Donor ID Donor Name: Last First

Donor Center Histocompatibility Typing Was HLA typing performed on this donor? Y N U Date Typed: If donor HLA typed, complete the remainder of this section. If donor was not HLA typed or typing status is Unknown, sign and return the form.

Target Source: (Select one) Peripheral Blood Lymphocytes Multiple Lymph Nodes Thymocytes Spleen Cell lines/Clonal Cells Solid Matrix

Typing Method Class I: Typing Method Class II: Serology Other, specify: Serology Other, specify: DNA DNA

A: Bw4: DR: DQ: A: Bw6: DR: DQ: B: Cw: DR51: DPw: B: Cw: DR52: DPw: DR53:

Recipient of a Living Donor Information

SSN: Organ: Living Recipient Name: Last First

Tx Provider Number: Center Code: Tx Center Name:

Haplotype Match Information:(Select one) 0 0.5 1 1.5 2 Unk N/A Donor Not Typed

UNOS/PHS/HCFA 11/9/00

Person completing form: Date completed: Recipient Histocompatibility Form (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 1 Provider Information

Lab Provider Number Center Code Lab Center Name Tx Provider Number Center Code Tx Center Name Recipient Information Organ(s): Name: Transplant Date: Last First MI DOB: SSN: HIC: Gender: Male Female

Donor Information Donor Type: Section III - Crossmatch A. Most Recent UNOS Donor ID Donor Name: Last First Serum Date: Cell Type:Target Source:Technique:Result: Test Information HLA typing done: Y N If Yes, complete Section I. PRA testing done: Y N If Yes, complete Section II. Crossmatch done: Y N Auto Crossmatch positive: Y N Not done U If Yes, complete Section III. Donor retyped at your center: Y N B. Positive Crossmatch with any other sera by any other If Yes, complete Section IV. method: Y N Section I - Recipient HLA Typing If Yes, give most recent positive Serum Date(s): Serum Date: Cell Type:Target Source:Technique:Result: Date Typed: Cell Source: (Use code) Typing Method Class I: Serology Other, specify: DNA

A: Bw4: Auto Crossmatch positive: Y N Not done U A: Bw6: B: Cw: B: Cw: Section IV - Donor Retyping Date Typed: Typing Method Class II: Cell Source: Serology Other, specify: (Use code) DNA Typing Method Class I: DR: DQ: Serology Other, specify: DR: DQ: DNA DR51: DPw: A: Bw4: DR52: DPw: A: Bw6: DR53: B: Cw: Section II - Panel Reactive Antibody (%PRA) B: Cw: Most Recent Serum Date: Typing Method Class II: Cell Type: Cell Source: Technique: PRA%: Serology Other, specify: DNA DR: DQ: DR: DQ: Peak Serum Date: DR51: DPw: Cell Type: Cell Source: Technique: PRA%: DR52: DPw: DR53:

UNOS/PHS/HCFA 1/28/00

Person completing form: Date completed: Kidney Transplant Recipient Follow-Up Form (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 2

Provider Information Follow-Up care provided by: Transplant Center Provider Number Center Code Transplant Center Name Non-Transplant Center Specialty Physician Primary Care Physician (HMO/PPO) Follow-Up Provider Number Center Code Follow-Up Center Name Other, specify:

Physician Name Physician UPIN City State Zip Recipient Information Transplant Date: Name: Discharge Date: Last First MI DOB: SSN: HIC: Gender: Male Female

Donor Information Donor Type: Employment Status (Select one) (Working = Employed, Home, School) Working Full Time

UNOS Donor ID Donor Name: Last First Working Part Time By Choice Working Part Time Due to Disease Patient Status at Time of Follow-Up (Select one) Working Part Time, Reason Unknown Date: Patient Report, Death or Retransplant Not Working By Choice Living Not Working Due to Disease Dead Cause of Death: (Use code) Not Working, Unable to Find Employment Specify: Not Working, Reason Unknown Retired Lost to Follow-Up Retransplanted since last Follow-Up Employment Status Unknown Patient Less Than Five Years Old Patient transferred to new provider: Y N If Yes, transferred to UNOS member Y N Clinical Information Transfer Date: Height ft. in. OR cm Weight lbs. OR kg New Provider Number New Provider Name

Hospitalizations during follow-up period: Y NU Graft Status Functioning Failed Number of transplant related hospitalizations: Dialysis since last follow-up: Y NU Resumed maintenance dialysis Y NU Was patient in ICU: Y NU If Yes, date resumed: Dialysis center provider #: Noncompliance Dialysis center name: Patient noncompliant during follow-up period: Y NU If Yes, indicate areas of noncompliance If functioning, most recent Serum Creatinine: mg/dl Immunosuppression medication Patient unable to afford immunosuppression medications Other medication If failed, failure date: Other medication, specify: Cause of graft failure (Check Yes, No or Unknown for each Other therapeutic regimen contributory cause of graft failure) Other therapeutic regimen, specify: Primary (Check one) Contributory Acute rejection Y NU Functional Status at Follow-Up (Select one) (How does the patient Chronic rejection Y NU perform activities of daily living?) Primary failure No activity limitations. (NYHA Class I or Class II) Graft thrombosis Y NU Performs activities of daily living with some assistance. Infection Y NU (NYHA Class III) Urological complications Y NU Performs activities of daily living with total assistance. Recurrent disease Y NU (NYHA Class IV) Other: Other: N/A Patient hospitalized Unknown

UNOS/PHS/HCFA 5/07/01 Kidney Transplant Recipient Follow-Up Form FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Name: Page 2 of 2 Patient treated for rejection: Y NU Number of rejection events:

Serology HIV Screening P N U ND I C Confirmation P N U ND I C CMV IgG P N U ND I C IgM P N U ND I C DNA P N U ND I C Hepatitis B Core Antibody P N U ND I C Surface Antigen P N U ND I C HBV DNA P N U ND I C Hepatitis C Antibody Screen P N U ND I C RIBA Test P N U ND I C HCV RNA P N U ND I C Epstein Barr Virus IgG P N U ND I C IgM P N U ND I C DNA P N U ND I C

Post transplant malignancies* Y NU Please report each type of Malignancy only once in the follow-up process. Donor related Y NU Recurrence of pre-transplant tumor Y NU Post Tx De Novo solid tumor Y NU Post Tx Lymphoproliferative Disease and Lymphoma Y NU * If Yes, complete Post Transplant Malignancy form.

Treatment Immunosuppressive Information Were any medications given during the follow-up Y N period for maintenance or anti-rejection: If no maintenance medications are currently Y N given, did the physician discontinue all immunosuppressive medications: Did the patient participate in any clinical Y N research protocol for immunosuppressive medications: If Yes, specify:

Other Therapy Photopheresis Y N Plasmapheresis Y N Total Lymphoid Irradiation (TLI) Y N

Biologicals/Vaccines Cytogam (CMV) Y N Gamimune N 10% Y N Gammagard SD Y N Acyclovir (Zovirax) Y N Ganciclovir (Cytovene) Y N HBIG (Hepatitis B Immume Globulin) Y N Flu Vaccine (Influenza virus) Y N Other: Other:

UNOS/PHS/HCFA 3/29/01

Person completing form: Date completed: Immunosuppression Treatment Follow-Up (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 1 Recipient Information

Name: Last First MI

Provider Number Center Code Tx Center Name Donor Information

Donor Type: UNOS Donor ID Donor Name: Last First

Immunosuppression Therapy All Maint Maint since last at time Anti-rej STEROIDS report of report Prednisone (Deltasone, Orasone) Methylprednisolone (Solu-medrol, Medrol, A-Methapred) T-CELL ACTIVATION INHIBITORS Cyclosporin A (CSA, Sandimmune, CyA, CyS) Neoral (CyA-NOF) FK506 (Prograf, Tacrolimus) Deoxyspergualin (DSG, 15-DSG, Gusperimus, Spanidin) Rapamycin (RAPA, Sirolimus, Rapamune) Gengraf (Abbot CyA) Certican (RAD, Enverolimus) ANTIMETABOLITES Azathioprine (AZA, Imuran) Mycophenolate Mofetil (MMF, Cellcept, RS61443) Cytoxan (Cyclophosphamide) Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) Brequinar Sodium (BRQ) Leflunomide (LFL) Mizoribine (Bredinin) ANTI-LYMPHOCYTE RECEPTOR ANTIBODIES T10B9 (Medimmune) ATG (Atgam, Anti-thymocyte Globulin)/NRATG/NRATS OKT3 (Orthoclone, Muromonab) Thymoglobulin Zenapax Simulect DAB486 - IL - 2 Anti - ICAM - 1 CYTOKINE INHIBITORS IL - 1 Receptor Antagonist Anti - IL - 6

OTHER IMMUNOSUPPRESSIVE MEDICATION Other: Other:

UNOS/PHS/HCFA 11/30/00

Person completing form: Date completed: