Request for Study Visit Lab Kits & ABPM/ActiGraph Devices

Requester's Email:
Date of Request:   
/ /
Site #:
Site Name:
Coordinator Name:

Does site have IRB approval
for February 2019 Amendment:
Yes No

Study Coordinator Contact Information (Location where ABPM/ActiGraph will be mailed)
IF YOU ARE REQUESTING AN ABPM DEVICE OR THIS IS FIRST TIME PLACING ACTIGRAPH REQUEST, PLEASE ENTER NAME AND ADDRESS BELOW.
   No change in contact information since previous request
Name:
Address:
 
 


Phone:
E-mail:
 
Date of Study Visit:  / /
Scheduled Tentative

KID ID#:  - -


Protocol Type (ONLY one type of protocol can be selected)
Regular Visit
Irregular (Accelerated) Visit
Repeated Study Visit (if no blood collected at initial visit)
Make-up GFR Visit (GFR samples ONLY, labs previously obtained)
Dialysis (Post RRT Visit)
Transplant (Post RRT Visit)
Transplant Make-up GFR Visit (GFR samples ONLY, labs previously obtained)

Visit #:  1a 1b 2 3 4 5 6 7 8 9 10
              11 12 13 14 15 16 17 18 19 20
Dialysis Visit #:  1a 1b 2 3 4 5 6 7 8 9 10
Transplant Visit #:  1a 1b 2 3 4 5 6 7 8 9 10

FOR POST RRT VISIT REQUEST ONLY
Has there been a change in modality (i.e., Transplant or Dialysis) since the last post RRT visit?
      Yes No

LABORATORY KITS
NO CBL or NIDDK Specimen Kits (ONLY requesting ABPM and/or Actigraph devices)
CBL Iohexol Visit Kit
CBL Specimen Kit (NO Iohexol)
Biological Serum & Plasma Specimen Kit (for NIDDK BR)
Biological Hair & Nail Specimen Kit (for NIDDK BR)
Biological Toenail Specimen Kit (for NIDDK BR)
Genetic Whole Blood Kit (for NIDDK BR)
Neither-Biological or Genetic Kits (Consent NOT Obtained)
 
Pharmacist Contact Information
   No change in contact information since previous request
Name:
Address:
 
 


Phone:

REQUEST FOR ABPM/ ACTIGRAPH
ABPM
      Note: Order ABPM for regular even-numbered study visits, post RRT baseline visits (Dialysis V1a, Transplant V1a) and all post RRT even-numbered post RRT visits.

ACTIGRAPH (Accelerometry/Physical Activity Monitor)
      Note: Order ActiGraph for all regular and post RRT visits, except V1a (i.e., regular V1a, Dialysis V1a and Transplant V1a)
FOR ACTIGRAPH REQUEST ONLY:
Current age:
Will this participant need the larger sized strap?   
Yes     No     Do Not Know    
Specify time zone if different from site’s time zone (optional):
Participant Information
Rate how likely the family would be to comply with the study protocol (i.e., wear the device consistently and return the device within designated time).
very likely likely unlikely very unlikely

COMMENTS
Enter in the comments box any relevant/pertinent information you would to communicate to the CBL, ABPM, DCC and/or CCC (e.g., do not send iohexol vial, please send sanizide plus, etc.).
Comments