1. Annual Status Report

NWTSID

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* NWTSID

Last 4 digits of Social Security # (optional)

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* Last 4 digits of Social Security # (optional)

Participant's name

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* Participant's name

Participant's Date of Birth

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* Participant's Date of Birth

Date of last contact

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* Date of last contact

Please provide all known information
Weight

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* Weight

Unit

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* Unit

Height

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* Height

Unit

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* Unit

If this participant has had any of the following illnesses or conditions resulting in hospitalization, surgery or other medical treatment since last report, or if previously unreported, please use the space below to report each event.

If reporting relapse of Wilms tumor, please mail or fax detailed flowsheets in addition to this form.
  • Heart disease or congestive heart failure
  • Cancer (after first Wilms tumor)
  • Renal failure, kidney problems or transplant
  • Other serious illness or medical conditions
Events to report

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* Events to report

First Event

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* First Event

First Event Date

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* First Event Date

Description/Outcome/Treatment of First Event

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* Description/Outcome/Treatment of First Event

Second Event

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* Second Event

Second Event Date

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* Second Event Date

Description/Outcome/Treatment of Second Event

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* Description/Outcome/Treatment of Second Event

Third Event

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* Third Event

Third Event Date

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* Third Event Date

Description/Outcome/Treatment of Third Event

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* Description/Outcome/Treatment of Third Event

Additional Comments

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* Additional Comments

Has this participant experienced any significant life events (such as marriage, pregnancy or parenthood) since last report?

If yes, or if previously unreported, please use the space below to report each event. For pregnancies, include date pregnancy ended, duration of pregnancy and outcome.
Events to report

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* Events to report

First Event

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* First Event

First Event Date

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* First Event Date

Description/Outcome of First Event

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* Description/Outcome of First Event

Second Event

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* Second Event

Second Event Date

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* Second Event Date

Description/Outcome of Second Event

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* Description/Outcome of Second Event

Third Event

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* Third Event

Third Event Date

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* Third Event Date

Description/Outcome of Third Event

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* Description/Outcome of Third Event

Additional Comments

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* Additional Comments

Name of person completing the form

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* Name of person completing the form

Survey Date

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* Survey Date

Thank you!

Your participation is an important contribution to our research

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