Local ID
Enter a subject identifier, up to ten characters are allowed. This ID is used by the center to identify the subject. Examples include subject initials, medical record number, etc.
Date of birth __________
Enter the donor’s date of birth as MM/DDD/YYYY.
Date Kidney Tolerance informed consent signed __________
Enter the date the donor provided consent as MM/DDD/YYYY.
Age __________
The system will generate an answer based off the donor’s date of birth. This field requires no response from the study site and cannot be edited.
Gender
Indicate the donor’s biological sex
- Male
- Female
- Other gender
- Gender unknown/Not reported
Race
Indicate the donors’s race as one of the following:
Native American or Alaska Native
Includes persons having origins in any of the original peoples of North, South, or Central America.
Asian
Includes persons with ancestors in any of the original peoples of the Far East, the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand, Vietnam, Hmong, East India, Laos, Bangladesh, Indonesia, Sri Lanka, Nepal, Bhutan, Sikh, Burma, and other South and Southeast Asian.
Black or African American
Includes persons having origins in any of the Black racial groups of Africa, including Black Americans, Africans, Haitians, and residents of Caribbean Islands of African descent.
Native Hawaiian or Other Pacific Islander
Native Hawaiian refers to persons having origins in any of the original peoples of the Hawaiian Islands, Guam or Samoa. Pacific Islander refers to persons having origins in any of the peoples of the Pacific Islands.
White or Caucasian
Includes persons who indicate their race as White such as Canadian, German, Italian, Lebanese, Near Easterner, Arabian, Eastern European, etc.
Not reported or unknown
Indicate if the participant declines to report a race or if participant’s race was not documented.
Other race, specify
Indicate and specify if the participant’s reported race does not fall into one of the above categories.
If the race is indicated as “Other race, specify”, specify the race in the text box.
Ethnicity
Indicate the participants ethnicity as either “Hispanic”, “Not Hispanic”, or “Latino”.
Hispanic or Latino
Hispanic or Latino refers to people whose ancestors or descendants originated in Central and South America and in the Caribbean, who follows the customs and cultures of these areas and who may speak Spanish.
The phrase Hispanic or Latino excludes people born in Europe whose language is Spanish or Portuguese, and non-Spanish speaking people born in Brazil, Belize, French Guyana, Guyana, Surinam and other non-Spanish speaking territories.
Not Hispanic or Latino
Specify of any ethnicity other than Hispanic.
Not reported or unknown
Indicate if the participant declines to provide this information or if the participant’s ethnicity is not documented.
CCG v.1 | CRF v.1
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