1. 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

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

3. 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

4. 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

5. 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)