** Denotes required information

Biopsy Report Form

Site Code: **       Accrual Number: **       Initials: **
Patient Key:
For a list of site codes, click here. If no middle initial, use 'X'. Patient Key will be of the form XXXXXX-000-XXX
Date of Biopsy:

(mm/dd/yyyy)
Organ Biopsied:
Results of Biopsy:
Rejection Grade:
Fibrosis Grade: