77 Ill. Adm. Code 2800.APPENDIX C
C Addendum II - Facility Experience
Section 2800
Section 2800.APPENDIX C
Addendum II - Facility Experience
FACILITY:
TYPE OF TRANSPLANT:
PERIOD COVERED*:
PATIENT**
AGE
DISEASE
TRANSPLANT
DATE
RETRANSPLANT
STATUS
*All patients in most recent
twelve-month period.
**If funded by Experimental Organ Transplantation Program,
indicate patient's name; otherwise use identifier only.