Skip to content

National Wilms Tumor Study Annual Status Report - Completed by participant/family

4.Annual Status Report

NWTSID - ok to leave blank if unknown
Email Address
Participant's Initials
Participant's Date of Birth
Zipcode
Last 4 digits of Social Security # (optional)

If 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.

  • Heart disease or congestive heart failure
  • Cancer (after first Wilms tumor)
  • Renal failure, kidney problems or transplant
  • Other serious illness or medical conditions
If yes please use the spaces below to report each event
Events to report
First Event
First Event Date
Description/Outcome/Treatment of First Event
Second Event
Second Event Date
Description/Outcome/Treatment of Second Event
Third Event
Third Event Date
Description/Outcome/Treatment of Third Event
Additional Comments

Has 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
First Event
First Event Date
Description/Outcome of First Event
Second Event
Second Event Date
Description/Outcome of Second Event
Third Event
Third Event Date
Description/Outcome of Third Event
Additional Comments