Appendix A – Adverse Event Definitions
Appendix F – Quality of Life Questionnaires
EQ-5D: Please contact the DCC for a copy of the EQ-5D survey
English Pediatric Quality of Life Questionnaire
- Parent Report for Toddlers (ages 2-4)
- Young Child Report (ages 5-7)
- Parent Report for Young Child (ages 5-7)
- Child Report (ages 8-12)
- Parent Report for Child (ages 8-12)
- Teen Report (ages 13-18)
- Parent Report for Teen (ages 13-18)
French Pediatric Quality of Life Questionnaire
- Parent Report for Toddlers (ages 2-4)
- Young Child Report (ages 5-7)
- Parent Report for Young Child (ages 5-7)
- Child Report (ages 8-12)
- Parent Report for Child (ages 8-12)
- Teen Report (ages 13-18)
- Parent Report for Teen (ages 13-18)
Spanish Pediatric Quality of Life Questionnaire
- Parent Report for Toddlers (ages 2-4)
- Young Child Report (ages 5-7)
- Parent Report for Young Child (ages 5-7)
- Child Report (ages 8-12)
- Parent Report for Child (ages 8-12)
- Teen Report (ages 13-18)
- Parent Report for Teen (ages 13-18)
Appendix G – Trail Making Test (Part B)
Intermacs only. Click here for Intermacs appendices.
Appendix I – Stroke Scales
Appendix J – Data Access Request
Click here for more information in regards to Data Access Requests
Appendix K – Device Brand List
Appendix M – Intermacs Users’ Guide
Intermacs only. Click here for Intermacs appendices.
Appendix N – Pedimacs Users’ Guide
Appendix O – Profiles of Advanced Heart Failure
Appendix P – Intermacs Data Collection Forms
Intermacs only. Click here for Intermacs appendices.
Appendix Q – Pedimacs Data Collection Forms
- Screening Log
- Demographics
- PreImplant
- Implant
- Implant Discharge
- 1 Week Followup
- 1 Month Followup
- 3 Month Followup
- 1 Year Post Cessation
- Adverse Event
- Adverse Event – Pump Change (new)
- Patient Transfer
- Withdraw Consent