Indicate the date of discontinuation _______
Enter the date the subject was discontinued from the study in the DD/MMM/YYYY format.

Indicate the reason for discontinuation
Provide the reason from the list below for why the subject was discontinued from the study.

  • Completion of study
  • Death
  • Kidney graft loss or failure
  • Physician decision
  • Study terminated by sponsor
  • Site terminated by sponsor
  • Patient withdrew consent
  • Lost to follow up
  • Other

If Death, specify cause of death _______

If Physician decision, specify reason _______

If Lost to follow up, specify last contact date _______

If Lost to follow-up specify reason _______

If other reason, specify _______

CCG v.1 | CRF v.1

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