Date of evaluation:
Report the date the frailty assessment was completed in DD/MMM/YYYY format.
Visit type
This field is required for all assessments conducted after April 14, 2020. Indicate the type of visit from the options available:
- In-person
- Remote: audio-visual teleconference
- Remote: telephone
Height and weight measurements
Current height:
Per protocol, the subject’s height must be measured within 21 days prior to the start of conditioning. Report the subject’s documented height in centimeters. Enter the height in “NNN” format. This format allows for up to three digits prior to the decimal and no digits after the decimal.
Date measured:
Enter the date when the subject’s height was measured in DD/MMM/YYYY format.
Current weight:
Per protocol, the subject’s weight must be measured within 21 days prior to the start of conditioning. Report the subject’s documented weight in kilograms. Enter the weight in “NNN” format. This format allows for up to three digits prior to the decimal and no digits after the decimal.
Date measured:
Enter the date when the subject’s weight was measured in DD/MMM/YYYY format.
Weight 1 year ago:
Report the subject’s weight one year ago in kilograms or pounds. Enter the weight in “NNN” format. This format allows for up to three digits prior to the decimal and no digits after the decimal. Weight loss pre-transplant reflects the prior year. Weight loss at day 100 and day 180 will be asked for the prior 3 months to reflect time since the prior assessment. At day 365, weight loss will be asked over the prior 6 months.
If weight loss in past year: “It seems that you have lost weight over the past year. Did you know that you had lost weight?”
Indicate “Yes” if the subject was aware that they have lost weight over the past year and request clarification from the subject whether they were trying to lose weight in the following question. Indicate “No” if they were not aware that they have lost weight over the past year.
If yes to knowing about weight loss, “Did you lose/gain weight because you were trying to, or not?” (for example, by dieting or exercising)
Select from the options below regarding whether the subject was trying to lose weight:
- Tried to
- Did not try to
- Don’t know
- Refused
Grip test measurement
Which hand do you use to sign your name? (This is the Dominant Hand)
Report “right hand” or “left hand” from the drop-down menu.
Have you had any recent pain in your hand or wrist or any acute flare-up in your hand or wrist from conditions like arthritis, tendonitis, or carpal tunnel syndrome?
Report “Yes” or “No” from the drop-down menu.
Have you had any surgery on your hands or arms during the last 3 months?
Report “Yes” or “No” from the drop-down menu. If the subject reports surgery in the past 3 months, do not test this hand.
If yes, which hand or arm (check all that apply)
If the subject answers “Yes” to having surgery, specify which hand or arm. Note, check all that apply.
Was the grip test completed?
Per protocol, to measure the grip strength, participants attempt to squeeze the dynamometer maximally 3 times with the dominant hand. Report whether the recipient completed the grip test by using the drop-down menu to select “Yes” or “No.”
Record grip strength measurement:
If the recipient completed any of the 3 grip tests, report the grip strength measurement in kilograms (round down to the nearest whole kilogram) for each of the three assessments. Enter the weight in “NNN” format. This format allows for up to three digits prior to the decimal and no digits after the decimal.
If no (grip test NOT completed), please select the reason
If the grip test was not completed, indicate the reason why it was not done from the options below:
- Attempted, but unable
- Examiner felt it was unsafe
- Participant felt it was unsafe
- Participant unable to understand instructions
- Participant refused
If the reason is not available in the drop-down options, report “Other, specify” and indicate the reason why the grip test was not done (up to 100 characters).
Walking test measurements
Was the first walking test completed?
Per protocol, to complete the walking test the participant will walk a pre-measured 4-meter length twice at his or her usual pace. Report “Yes” or “No” to whether the first walking test was completed.
If Yes, record the time:
Record the time the first trial took in seconds. Enter the time in “NN.N” format. This format allows for up to two digits prior to the decimal and one digit after the decimal. Round up to the nearest tenth for the walk speed test time (i.e. 3.93 seconds = 3.9 seconds; 3.95 seconds = 4.0 seconds; and 3.98 seconds = 4.0 seconds)
If No, (Walking speed test was NOT completed) please mark for the reason
If the participant was unable to complete the first trial, indicate the reason why from the options below:
- Attempted by unable
- Examiner felt it was unsafe
- Participant felt it was unsafe
- Participant cannot walk even with support
- Participant unable to understand instructions
- Participant refused
If the reason why the participant did not complete the first trial is not available, indicate “Other, specify” and report the reason.
Was the second walking test completed?
Per protocol, to complete the walking test the participant will walk a pre-measured 4-meter length twice at his or her usual pace. Report “Yes” or “No” to whether the second walking test was completed.
If Yes, record the time:
Record the time the second trial took in seconds. Enter the time in “NN.N” format. This format allows for up to two digits prior to the decimal and one digit after the decimal. Round up to the nearest tenth for the walk speed test time (i.e. 3.93 seconds = 3.9 seconds; 3.95 seconds = 4.0 seconds; and 3.98 seconds = 4.0 seconds)
If No, (Walking speed test was NOT completed) please mark for the reason
If the participant was unable to complete the second trial, indicate the reason why from the options below:
- Attempted by unable
- Examiner felt it was unsafe
- Participant felt it was unsafe
- Participant cannot walk even with support
- Participant unable to understand instructions
- Participant refused
If the reason why the participant did not complete the second trial is not available, indicate “Other, specify” and report the reason.
CCG v.4.0 | CRF v.3.0
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