Eligibility Questionnaire

Please complete the following screening questionnaire to see if you are eligible to participate in this study.

By completing this eligibility form, you consent to your information being collected. This information will be used to assess your eligibility for this study which means that you can participate. If you are found eligible, this information will also be used to direct you to the appropriate study participation consent form. You can then begin the consent process. If you do not complete this eligibility form or if you are found to be ineligible for this study, the information you provided will not be saved.

	Eligibility questions
	Are you a transplant recipient?	Yes, an organ transplant Yes, a stem cell transplant No
	Which transplant center oversees your medical care?	BC Children’s Hospital Vancouver General Hospital and/or St. Paul's Hospital University of Alberta Hospital Stollery Children's Hospital SickKids University Health Network London Health Sciences Center Institut de Cardiologie de Montréal CHUM CHUQ (CHU de Québec) Montreal Children's Hospital Site not listed
	Are you on at least one immunosuppressant?	Yes No
	If autologous transplant recipient, are you within 12 months of receiving a stem cell infusion?	Yes No
	Are you involved in caring for a transplant recipient?	Yes, for an adult solid organ transplant recipient Yes, for an adult stem cell transplant recipient Yes, for a child who has received a solid organ transplant No
	Please enter the study participant identifier of the transplant recipient (## -X-XXX- ####)
	What is your birthdate?	Month:  - Select - January February March April May June July August September October November December     Year:  - Select - 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025