Recipient 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 recipient has signed the Informed Consent for participation in the Kidney Transplant Tolerance Induction Protocol.

Recipient Eligibility

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

• Yes
• No
  

Date of kidney transplant __________
Enter the date of kidney transplant as MM/DDD/YYYY. If the date of the kidney transplant changes, update this field to reflect the actual transplant date.

Does the recipient meet the standard institutional criteria for autologous cell collection?
Indicate if the participant 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 the language of the Kidney Tolerance Study informed consent used to obtain participant (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 participant (or legal guardian) consent. Indicate the version number and/or version date.

System generated answers

Does the recipient meet protocol criteria for enrollment in this trial?
The system will generate an answer based off (enter how answer is generated). This field requires no response from the study site and cannot be edited.

• Yes
• No
  

Subject Status
The system will generate an answer based off (enter how answer is generated). This field requires no response from the study site and cannot be edited.

• Enrolled
• Early Terminated
• Completed
  

  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.