CKiD Study Lab Kit Request Form
Date of Request:
-
Month
-
Day
Year
Site Name:
*
Please Select
01- Children's Mercy Hospital
02- Medical College Wisconsin
03- University of New Mexico
04- Oregon Health and Science
05- Cincinnati Children's
06- Stanford University
07- Boston Children's
08- British Columbia Children's
09- Children's Hospital of Alabama
10- Washington University St Louis
11- Case Western Reserve
12- University of Wisconsin
13- Oklahoma University
15- Seattle Children's
17- University of Manitoba
20- UCLA
21- UCSD
22- University of Texas Southwestern
25- UCSF Children's Hospital
27- Phoenix Children's Hospital
28- CHOA Emory
50- Johns Hopkins
51- Children's Hospital Michigan
52- Lurie Children's Hospital
53- Children's National Medical Center
54- Nationwide Children's Hospital
55- Inova Fairfax Hospital
57- Riley Hospital, Indiana University
59- University of Michigan
61- University of Texas, Houston
64- Children's Hospital Montefiore
65- University of Iowa
68- Mount Sinai Medical center
70- Texas Children's Hospital, Baylor
72- University of Rochester Medical Center
73- University of Virginia
74- Robert Johnson Medical School
76- AI duPont Hospital for Children
79- Devos Children's Hospital, Spectrum Health
80- Carolinas Medical Center
81- SUNY Downstate Medical Center
82- University of Illinois at Chicago
83- CHOP
84- Hospital for Sick Children
85- East Carolina University
86- Children’s Hospital at Dartmouth
88- University of Kentucky
89- Loma Linda University
90- St Joseph's University Medical Center
91- Tulane University
92- University of Louisville
93- University of Miami
94- Driscoll Children's Hospital
Coordinator Contact Information
Coordinator Name:
*
Coordinator Email:
*
Coordinator Phone Number:
*
Coordinator Address:
*
Visit Information
CKiD Protocol currently approved at your site:
*
October 2024
May 2022
KID
*
Date of study visit:
*
-
Month
-
Day
Year
(date can be tentative)
Age of participant at time of visit:
*
Protocol Type (select one):
*
Regular Visit
Dialysis (Post KRT Visit)
Transplant (Post KRT Visit)
Transplant Make-up GFR Visit
Visit Number
*
Please Select
Re-entry visit
1 Baseline
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Lab Kits (select all that apply) :
*
RFU/Post-KRT Transplant (CBL Specimen Collection Kit)
Post-KRT Dialysis (CBL Specimen Collection Kit)
Iohexol GFR Kit
Frozen Repository (Serum/Plasma) (for NIDDK Repository)
Frozen Repository (Urine) (for NIDDK Repository)
Genetic Whole Blood Kit (for NIDDK Repository)
REMINDER: Remember to also select the CBL Specimen Collection Kit. Iohexol GFR studies should be performed for post-KRT transplant participants ONLY.
Reminder: Genetic blood samples are only collected one time per participant. The genetic whole blood kit does not need to be ordered if genetic samples were previously collected.
Pharmacist Name:
Pharmacist Phone:
Pharmacist address :
Comments: Enter any relevant information you would like to communicate to the CBL, CCC or DCC.
ckidship email
Site Number
Submit
Should be Empty: