IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 [Before completing please read instructions at the bottom of this page a nd on pages 4, 5 and 6] PATIENT IDENTIFICATION MAKE C ORRECTIONS TO PATIENT INFORMATION ON LABEL IN THE SPACE BELOW Place Patient Data Label Here 12. If this patient is unknown or was not dialyzed in the facility at any time during OCT 2004-DEC 2 004 return the blank form to the Network. 13. Patients Ethnicity (Check appropriate box). o non-Hispanic o Hispanic, Mexican American (Chicano) o Hispanic, Puerto Rican o Hispanic, Cuban American o Hispanic, Other o Unknown 14. Patients height (MUST COMPLETE): _________inches OR _________centimeters ( only for patients < 18 years old, provide date when height was measured: ____ / ___ / _____ ) (mm) (dd) (yyyy) 15. Did patient have limb amputation(s) prior to Dec. 31, 2004: o Yes o No o Unknown 16. Has the patient ever been diagnosed with any type of diabetes? o Yes (go to 17) o No (go to 18) o Unknown (go to 18) 17. If question 16 was answered YES , was the patient taking medications to control the diabetes during the stu dy period? o Yes o No o Unknown If YES , was the patient using insulin during the study period? o Yes o No o Unknown Individual Completing Form (Please print): First name: ___________________________ Last name: ___________________ _________________ Title: _______________ Phone number: (_______) _________ - __________ Fax number: (_______) _________ - ____________ INSTRUCTIONS FOR COMPLETING THE IN-CENTER HEMODIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 The label on the top left side of this form contains the following patient identifying information (#s 1-11). If the information is incorrect make corrections to the right of the label. 1. LAST and first name. 2. DATE of birth (DOB) as MM/DD/YYYY. 3. SOCIAL Security Number (SSN). 4. HEALTH Insurance Claim Number (HIC), (same as Medicare number). 5. GENDER (1=Male; 2=Female). 6. RACE (1=American Indian/Alaska Native; 2=Asian; 3=Black; 4=White; 7. PRIMARY cause of renal failure by 5=Unknown; 6=Pacific Islander; 7=Mid East Arabian; 8=Indian Subcontinent; CMS-2728 code. 9=Other/Multiracial). 9. ESRD Network number. 8. DATE, as MM/DD/YYYY, that the patient began a regular course of dialysis. Do not make corrections to this item. 10. Facilitys Medicare provider number. 11. The most RECENT date this patient returned to hemodialysis following: transplant failure, an episode of regained kidney function, or switched modality. 12. If the patient is unknown or if the patient was not dialyzed in the facility at any time during OCT 2004 through DEC 2004, send the blank form back to the ESRD Network office. Provide the name and address of the facility providing services to this patient on December 31, 2004, if known. 13. Patients Ethnicity. Please verify the patients ethnicity with the patient and check appropriate box. 14. Enter the patients height in inches or centimeters. HEIGHT MUST BE ENTERED, do not leave this field blank. You may ask the patient his/her height to obtain this information. If the patient ha d both legs amputated, record pre-amputation height and check YES for item 15. 15. For the purpose of this study, check NO if this patient has had toe(s), finger(s), or mid-foot (Symes) amputation; bcheckut YES if this patient has had a below-knee, below-elbow, or more proximal (extensive) amputation prior to Dec. 31, 2004. 16. Check either Yes, No, or Unknown to indicate if the patient has ever been diagnosed with any type of diabetes. If YES , proceed to question 17. 17. Check either Yes, No, or Unknown to indicate if the patient was taking medications to control the diabetes during the study period. If the answer to 17 is YES , please check either Yes, No, or Unknown to indicate if the patient was using insulin during the study period. Study period is OCT 2004-DEC 2004. American LegalNet, Inc.CMS 820 (Rev.1/27/05) PLEASE COMPLETE ITEM 18 ON PAGE 2 OF THIS DATA COLLECTION FORM, ITEMS 19 AND 20 ON PAGE 3, 21 AND 22 ON PAGE 4.www.USCourtForms.com>>>> 2 2 IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 (CONTINUED) 18. ANEMIA MANAGEMENT: For each lab question below, enter the 1st pre-dialysis lab value obtained for each month: OCT, NOV, DEC 2004. Include the date each lab was drawn. Enter NF/NP if the lab value cannot be located. OCT 2004 NOV 2004 DEC 2004 A. 1st pre-dialysis laboratory hemoglobin (Hgb)____ ____ . ____ g/dL ____ ____ . ____ g/dL ____ ____ . ____ g/dL of the month: (If NF/NP go to 18C) (If NF/NP go to 18C) (If NF/NP go to 18C) Date: ____/____/____ Date: ____/____/____ Date: ____/____/____ B.1.a. Did the patient have Epoetin prescribed at any Epoetin: Epoetin: Epoetin: time during the 28 days before the Hgb in 18Ao Yes o No o Yes o No o Yes o No was drawn? o Unknown o Unknown o Unknown B.1.b. Did the patient have Darbepoetin (Aranesp) Darbepoetin: Darbepoetin: Darbepoetin: prescribed at any time during the 28 days beforeo Yes o No o Yes o No o Yes o No the Hgb in 18A was drawn? o Unknown o Unknown o Unknown B.2.a. What was the PRESCRIBED Epoetin dose inEpoetin: Epoetin: Epoetin: units for each treatment during the 7 days immediately BEFORE the Hgb in 18A was ____________ units/tx ____________ units/tx ____________ units/tx drawn? (See instructions on page 4) ____________ units/tx ____________ units/tx ____________ units/tx ____________ units/tx ____________ units/tx ____________ units/tx B.2.b. What was the PRESCRIBED Darbepoetin doseDarbepoetin: Darbepoetin: Darbepoetin: in micrograms/28 days for the 28 days immediately BEFORE the Hgb in 18A was drawn? _________ mcg/28 days _________ mcg/28 days _________ mcg/28 days B.3.a. How many times per week was Epoetin Epoetin: Epoetin: Epoetin: prescribed? Check box if prescribed < 1 x per__________ x per week__________ x per week__________ x per week week. o < 1 x per week o < 1 x per week o < 1 x per week B.3.b. How many times per month (28 days) was Darbepoetin: Darbepoetin: Darbepoetin: Darbepoetin prescribed? _________ per 28 days_________ per 28 days ________ per 28 days B.4.a. What was the prescribed route of administrationEpoetin: Epoetin: Epoetin: for Epoetin? (Check all that apply) o IV o SC o Unknown o IV o SC o Unknown o IV o SC o Unknown B.4.b. What was the prescribed route of administrationDarbepoetin: Darbepoetin: Darbepoetin: for Darbepoetin? (Check all that apply)