CKiD Request for Study Visit Lab Kits
Requester's Email:
Date of Request:
/
/
Site #:
Site Name:
Coordinator Name:
Which protocol is currently approved at your site?
December 2020 Amendment
May 2022
Amendment
Study Coordinator Contact Information
No change in contact information since previous request
Name:
Address:
Phone:
E-mail:
Date of Study Visit (mm/dd/yy):
/
/
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
CBL Iohexol Visit Kit
CBL Specimen Kit (NO Iohexol)
Biological Serum & Plasma Specimen Kit (for NIDDK BR)
Genetic Whole Blood Kit (for NIDDK BR)
Neither-Biological or Genetic Kits (Consent NOT Obtained)
Pharmacist Contact Information
Name:
Address:
Phone:
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
: