Case Study Template Kerecis Aurora Awards Download case study template and consent form Fill out consent form and obtain appropriate consents Fill in slide 2 with your name, facility, submission category Fill out slide 3 with past wound history and management details Fill out slide 4 for current wound history and management For additional photos, copy slide 4 as many times as necessary to share wound progression When complete, submit case with consent form

Case Study Template Clinician Name and title Contact phone numbers Type of wound: ex. Diabetic ulcer Clinician Name and title Contact phone numbers Email Address Name of Affiliated Facility: Submission category Consent form submitted: Chronic wounds Surgical wounds Burns Resident Award Yes No

Past wound history and management Patient History: Age & sex Past medical and surgical history: Pertinent history to wound: Age of wound: Prior to starting Kerecis Omega3 Wound   Previous treatment: Ex: hydrogel, collagen dressings, NPWT, other cellular tissue base products Wound characteristic: Initial wound description Pain level and management

Name of wound: i.e. DFU- Left leg Current wound history and management Date of wound picture:   Wound measurement in cm : Brief Description: Wound characteristics: slough 10%, bone exposed Pertinent information on wound status and patient’s condition if applicable Pain level Wound progress: ex. Epithelialization, granulation For last slide, include clinical outcome Wound Treatment: ex: Kerecis Omega3 Wound secured with steri-strips covered with contact layer, silver dressing secured with roll gauze. Total contact cast Compression wrap Wound picture Name of wound: i.e. DFU- Left leg Aside from picture of wound, please include pictures of Kerecis on wound, application techniques, etc

THE COMMITTEE ON HUMAN RESEARCH Please ensure all patient identifiers are removed per the HIPPA Guidelines HIPAA-PHI: List of 18 IDENTIFIERS AND DEFINITION of PHI List of 18 identifiers: Names: all geographical subdivisions smaller than a state, including street address, city, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code, if according tot the current publicly available data from the Bureau of the Census: (1) The geographic unit formed by combining all of the zip codes with he same three initial digits contains more than 20,000 people; and The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000. All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates(including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older; Phone numbers; Fax numbers; Electronic mail addresses; Social Security numbers; Medical record numbers; Health plan beneficiary numbers; Account numbers; Certificate license numbers; Vehicle identifiers and serial numbers, including license plate numbers; Device identifiers and serial numbers; Web Universal Resource Locators (URLs); Internet Protocol (IP)address numbers; Biometric identifiers, including finger and voice prints; Full face photographic images and any comparable images; and Any other unique identifying number, characteristic, or code (note this does not mean the unique code assigned by the investigator to code data)