Yes	No
The fistula/graft does not have a pulsation (even with augmentation) at the anastamosis or the access body
The fistula/graft does not have a palpable thrill at the anastamosis or the access body
The fistula/graft does not have an audible bruit anywhere along the anastamosis or body (up to 10 cm from the anastamosis)
A radiological intervention such as angioplasty, thrombolysis, stenting, embolization or other will not salvage the access to be useable
A surgical revision will not salvage the access to be useable. Note: A revision means that it is a revision of the current access and not a surgical procedure that will effectively create new access
A reasonable effort has been made to improve the condition of the access in order for it to be used; for example, adequate elevation and time for rest of an infiltrated fistula
The access is viable but there are complications that require the abandonment of the access e.g. high cardiac output failure or severe steal syndrome
Other, indicate:_______________________________________
I confirm that the fistula or graft is officially abandoned for further use and is not safely salvageable