Donor Eligibility

*Timeline requirements for this form are as follows:
Assessment timeframe: At the time of eligibility assessment
Submission timeframe: Submit this form once the potential transplant donor has signed the Informed Consent for participation in the Kidney Transplant Tolerance Induction Protocol.

Does the donor meet the standard institutional criteria for kidney transplantation?
Indicate if the donor met the institution’s standard criteria for kidney transplantation.

• Yes
• No
  

Does the donor meet the standard institutional criteria for hematopoietic cell transplantation donation?
Indicate if the donor met the institution’s standard criteria for autologous cell collection.

• Yes
• No
  

Does the donor meet the protocol criteria for enrollment in this trial?
Indicate if the donor met the institution’s standard criteria for autologous cell collection.

• Yes
• No
  

Date of consent __________
Enter the date of consent as MM/DDD/YYYY.

Study ICF language __________
Report language of the Kidney Tolerance Study informed consent used to obtain donor or legal guardian consent. If a short form was used, report the language and indicate “short form”. For example, “Spanish short form”.

Study ICF Version __________
Report which version of the Kidney Tolerance Study informed consent was used to obtain donor or legal guardian consent. Indicate the version number and/or version date.

CCG v.1 | CRF v.1

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CIBMTR® (Center for International Blood and Marrow Transplant Research) is a research collaboration between the Medical College of Wisconsin and NMDP.