Request for Study Visit Lab Kits & ABPM Device

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 (Location where ABPM will be mailed)
IF YOU ARE REQUESTING AN ABPM DEVICE, 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 device)
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
   No change in contact information since previous request
Name:
Address:
 
 


Phone:

REQUEST FOR ABPM
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.

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