Test Results Immunosuppressive Drug Blood Levels

*Timeline requirements for this form are as follows:
Assessment timeframe: Week 3, Week 4, Week 5, Week 6, Week 7, Week 8, Week 9. Week 10, Week 11, Week 12, Week 13, Month 4.
Submission timeframe: Submit this form after the designated clinic visit with the recipient’s test results entered as indicated.

Date blood drawn __________
Enter the date the blood specimen was drawn. Enter the date as DD/MMM/YYYY.

Mycophenolic Acid (MPA) level reported _______ µg/mL
Enter the level of mycophenolic acid reported in µg/mL. Enter this in the “NNNNN” format. This format allows for five digits without a decimal.

MPA
Indicate the most appropriate description of the MPA level. Use appendix [“”] to determine if the MPA level is within or out of range per protocol

• Level in range for protocol
• Level out of range for protocol
• N/A, MPA level NOT reported for blood sample
• N/A, MMF discontinued
• MPA test not done
  

Tacrolimus blood trough level _______ µg/mL
Enter the level of tacrolimus blood trough reported in µg/mL. Enter this in the “NNNNN” format. This format allows for five digits without a decimal.

Tacrolimus
Indicate the most appropriate description of the tacrolimus level. Use appendix [“”] to determine if the tacrolimus level is within or out of range per protocol.

• Level in range for protocol
• Level out of range for protocol
• N/A, MPA level NOT reported for blood sample
• N/A, MMF discontinued
• MPA test not done
  

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