A Phase I/II Randomized Double-blinded Placebo-controlled Clinical Trial to Determine Safety and Feasibility of Using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients
Phase: PHASE1
Conditions: SARS CoV-2
Sponsor: University of Utah

 
 
 
 
TITLE: A PHASE I/II RANDOMIZED DOUBLE-BLINDED PLACEBO-CONTROLLED CLINICAL TRIAL TO DETERMINE SAFETY 
AND FEASIBILITY OF USING AN ACELLULAR STERILE FILTERED AMNIOTIC FLUID AS A TREATMENT FOR COVID-19 
PATIENTS 
 
VERSION DATE: 22NOV2021 
 
NCT #: 04497389 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Randomized, Double-Blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of Using an Acellular 
Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 22 NOV 2021 
 
1 
 
TITLE: 
A PHASE I/II RANDOMIZED DOUBLE-BLINDED PLACEBO-
CONTROLLED CLINICAL TRIAL TO DETERMINE SAFETY AND FEASIBILITY 
OF USING AN ACELLULAR STERILE FILTERED AMNIOTIC FLUID AS A 
TREATMENT FOR COVID-19 PATIENTS. 
 
 
Principal Investigator 
 
 
Craig Selzman, MD  
Division of Cardiothoracic Surgery  
Department of Surgery 
University of Utah 
Salt Lake City, Utah 
 
 
 
Sub-Investigators 
 
 
 
Nathan Hatton, MD 
Division of Pulmonary  
Department of Internal Medicine 
University of Utah 
Salt Lake City, Utah 
 
Joseph Tonna, MD 
Division of Cardiothoracic Surgery 
Department of Surgery 
University of Utah 
Salt Lake City, Utah 
 
Giavonni Lewis, MD 
Division of Burn/Wound Surgery 
Department of Surgery 
University of Utah 
Salt Lake City, Utah 
 
John Phillips, PhD 
Division of Hematology 
Department of Internal Medicine 
University of Utah 
Salt Lake City, Utah 
 
Jan Pierce, MBA 
Cell Therapy and Regenerative Medicine 
Department of Internal Medicine 
University of Utah 
Salt Lake City, Utah  
 
 
1. SYNOPSIS 

Randomized, Double-Blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of Using an Acellular 
Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 22 NOV 2021 
 
2 
 
 
Title 
A Phase I/II Randomized, Double-Blinded, 
Placebo-Controlled Clinical Trial to 
Determine Safety and Feasibility of Using an 
Acellular Sterile Filtered Amniotic Fluid as a 
Treatment for COVID-19 Patients. 
Short Title 
hAF for the Treatment of 
COVID-19 
IRB Number 
IRB: 00132922 
IND 
IND # 23369 
Phase 
Phase I/II 
Design 
This is a prospective double-blinded, 
randomized controlled study to 
determine the safety and feasibility of 
using processed sterile filtered amniotic 
fluid (hAF) to treat and reduce 
inflammation in COVID-19 patients. 
Study Duration 
1 year 
Study Center(s) 
University of Utah 
Objectives 
Primary Objectives: 
• To determine the safety of using 
processed human amniotic fluid 
(hAF) intravenously (IV) to treat 
patients with COVID-19. 
• To determine efficacy of hAF 
vs. placebo to reduce 
inflammation in COVID-19 
patients. 
• To determine clinical outcomes 
in patients treated with hAF vs. 
placebo. 
Number of Subjects 
60 patients (30 per treatment arm) 
Eligibility Criteria 
Inclusion: 
1. Age ≥18 
2. SARS-CoV-2 positivity by RT-PCR   
test, obtained within 14 days of 
enrollment 
3. Hospitalized 
4. COVID-19 symptomatic (cough, 
fevers, shortness of breath, and/or 
sputum production) 
5. Has a room air pulse oximetry of 
≤94% and requires supplemental 
oxygen therapy 
6. Patients of child bearing potential 
who agree to use acceptable methods 

Randomized, Double-Blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of Using an Acellular 
Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 22 NOV 2021 
 
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of contraception for 90 days after last 
administration of study IP  
7. Patients who are receiving standard 
of care therapies for COVID-19 that 
are not FDA approved are eligible for 
this study 
8. Patients must be able to consent to 
the study (e.g. Glasgow Coma Score 
of ≥ 14) 
9. Patients are required to have 
controlled blood pressure of < 160/96 
and have a pulse of <110 at the time 
of study drug administration. 

Randomized, Double-blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of 
using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 17 JUL 2020 
 
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Exclusion: 
1. Patients on invasive mechanical 
ventilation (e.g., endotracheal 
intubation) 
2. Chronic home oxygen utilization 
3. Clinically significant home use of 
immunosuppressive medications, 
including more than 20mg of steroid 
(e.g., prednisone) per day, 
monoclonal antibodies, or 
chemotherapy medications. Patients 
who are not chronically immune 
suppressed are eligible for 
participation. Patients who are 
prescribed steroids, including 
dexamethasone, for the purpose of 
treating COVID-19 prior to the 
patient’s study hospital admission 
will not be excluded. 
4. Women who are pregnant, 
breastfeeding or become pregnant 
during the study 
5. Patients on non-invasive positive 
pressure ventilation 
6. Patients on >12 liters per minute via 
non-rebreather (NRB) or >80% 
oxygen via high flow nasal cannula 
7. Patients who in the opinion of the 
Investigator has impending 
respiratory failure, defined as 
requiring rapidly escalating oxygen 
supplementation 
8. Patients with a hemoglobin < 9 
mg/dL 
9. Patients diagnosed with Stage 4 or 5 
chronic kidney disease (CKD) 
10. Patients with diagnosed with Class 3 
or 4 congestive heart failure (CHF) 
11. Patients with a left ventricular assist 
device (LVAD) 
12. Patients with current 
thromboembolic phenomena 
13. Patients with Type 2 and above heart 
block 

Randomized, Double-blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of 
using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 17 JUL 2020 
 
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14. Patients with established positive 
bacterial blood cultures prior to 
enrollment 
15. Patients with ongoing pericardial 
effusion, or ascites 
16. Patients with clinically significant 
arrhythmia 
17. Patients with liver function tests 
(ALT or AST) >3x normal 
18. Patients with untreated HIV infection 
19. Patients diagnosed with end-stage 
organ disease 
 Study Product, Dose, Route, Regimen 
hAF will be delivered to the clinical 
setting on the date of application. 
Dose is 10mL/day for 5 days; 
patients may be discharged prior to 
completing regimen.  
Route: Intravenous (IV) Push 
Statistical Methodology 
One goal of the analysis is to 
demonstrate safety, which does not 
require statistical significance.  
 
The other primary goal of the analysis 
is to assess efficacy of hAF by 
reducing inflammation in COVID-19 
patients, potentially leading to 
improved clinical outcomes.  This 
will be assessed by measurement of 
C-reactive protein levels before and 
after the intervention. 
Secondary outcomes include: 
1. Death within 30 days 
2. ICU-free days at 30 days  
3. Hospital length of stay 
4. Need for invasive mechanical 
ventilation 
5. Biomarker levels (interleukin-6, d-
dimer, lactate dehydrogenase) 
6. Need for ECMO 
7. Major adverse cardiac events 
8. Patient-reported functional status 
*Enrolled subjects will need to meet blood pressure requirements prior to IP administration, detailed below 
 

Randomized, Double-blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of 
using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 17 JUL 2020 
 
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2. STUDY OBJECTIVES 
 
The purpose of this study is to explore the effectiveness of processed human amniotic fluid as a 
treatment for COVID-19. Past use of human amniotic products (i.e., membrane and fluid) has 
previously been FDA-approved as a human cells, Tissues, and Cellular and Tissue-Based 
Products (HCT/P) under 21 CFR 1271 for tissue injury; and has been used to reduce 
inflammation and fibrosis in patients with a variety of ailments. Given this, we hypothesize that 
intravenously (IV) administered processed sterile filtered amniotic fluid will reduce 
inflammation in COVID-19 patients, and improve secondary clinical outcomes. Specifically, we 
hypothesize that patients who receive IV administered hAF will see a 50% reduction in mean C-
reactive protein levels following treatment. 
 
3. ENDPOINTS 
 
Primary Endpoint: 
• C-reactive protein (CRP) levels measured before and after treatment 
• Whether the patient experienced any post-randomization, study-related 
Adverse Events (AEs) while on study (up to 5 days) of treatment. 
 
Secondary Endpoint: 
• Other endpoints include mean days of supplemental oxygen, mean days of 
mechanical ventilation, mean ICU and hospital length of stay, and patient-
reported functional status. 
• Survival at days 7, 14, 60, 90 days post randomization. 
 
 
4. BACKGROUND AND HYPOTHESES 
 
Early data in the COVID-19 pandemic suggests that women who have given birth while actively 
infected may not transmit the virus to the baby, amniotic fluid, or breast milk.1-2 Given the use of 
amniotic products for treatment of inflammation in other situations, described below, our group 
proposes an experimental and innovative use of hAF as its impact on cardiopulmonary failure 
has not been previously investigated. We hypothesize that systemic administration of human 
amniotic fluid (hAF) may assist in decreasing inflammation in patients infected with COVID-19. 
 
Human amniotic membrane and human amniotic fluid have been shown to reduce 
inflammation,3-5 have antimicrobial properties,6-8 and low risk of immunogenicity.9 hAF is 
devoid of any cellular products (not to be confused with umbilical cord-derived, AF-derived 
stem cell products, or AF embolism). Purified hAF is a cell-free, non-antigenic solution of >1000 
proteins that mother nature developed. Hence, amniotic products make ideal biocompatible 
scaffolds for the treatment of diverse conditions, including intractable epithelial defects, burns, 

Randomized, Double-blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of 
using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 17 JUL 2020 
 
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diabetic/peripheral vascular ulcers, partial limbal cell deficiencies, peripheral nerve regeneration, 
tendon repair, and Stevens-Johnson syndrome.10-16 The University of Utah is well-poised to 
perform this investigation, as human amniotic membrane (hAM) is currently being used here as a 
clinical tissue allograft in burn patients, for digital ulcers in scleroderma patients, as a nerve wrap 
to protect nerves from adhesions post-surgery, and as trachea-stenosis-tracheal stent covering. 
Likewise, there is an ongoing study exploring post-cardiac surgery atrial fibrillation, thought to 
be associated with local and systemic inflammation, and the impact of using hAM as a substitute 
pericardial patch to decrease post-operative inflammation. While results are not yet available, the 
six (of twelve) patients who have randomized to treatment have had no ill effects from the 
placement of the membrane. With regard to fluid, hAF has been successfully injected into >500 
burn patients to augment graft survival at the University of Utah. hAF is also currently being 
used experimentally under IND approval at the University of Utah to treat ocular graft versus 
host disease and ocular PRK. An IRB application to study hAF to treat chronic wounds is 
pending. IND applications have been or are being submitted to the FDA to treat osteoarthritis 
and radicular lower back pain. 
 
In basic science laboratories here at the University of Utah, we have demonstrated that rats 
undergoing myocardial ischemia reperfusion have a marked decrease in myocardial injury and 
fibrosis if they receive either intramyocardial or systemic intravenous injection of hAF. Thus, 
there is conceptual attractiveness in the potential impact of systemic administration of hAF in 
COVID-19 patients. Many COVID-19 patients, in addition to succumbing to acute hypoxic 
respiratory failure, are plagued with cardiac manifestations including myocarditis, accelerated 
heart failure, and arrhythmias.17 Lung pathology specimens from the SARS-1 epidemic in 2005 
demonstrated diffuse alveolar damage with extensive fibrosis.18 Likewise, lung pathology in 
COVID-19 patients undergoing lung resection for lung cancer (i.e., non-autopsy pathology) 
revealed edema and patchy, inflammatory cellular infiltrates, particular with macrophages.19 As 
COVID-19 causes an aggressive inflammatory and fibrotic response, this suggests that hAF, by 
mitigating inflammation and decreasing fibrosis, could impact the natural history of COVID-19 
infected patients.  
 
Importantly, the University of Utah is home to the Cell Therapy and Regenerative Medicine 
(CellReGen) program. CellReGen is unique in the world for being able to process and 
manufacture hAF for clinical use.20 hAF has previously been FDA-approved as a human cellular 
and tissue product (HCT/P) under 21 CFR 127121 for tissue injury. It has been generated by 
CellReGen, utilized widely, and safely used in thousands of patients without demonstrable 
toxicity. If hAF proves effective, we are confident that CellReGen could mobilize mass 
quantities of hAF in a relatively short period of time, which could be used to treat COVID-19 
nationally.  
 
Ten patients were enrolled in a pilot study. These patients were diagnosed with COVID-19 by 
SARS-CoV-2 positivity by RT-PCR test.  Patients were 40% female with an average age of 51.9 
years old (range 24-76). Patients were 50% white, with two patients identifying as American 
Indian/Alaskan Native, three patients identifying as Hispanic (one Hispanic/white), and one as 
unknown or other.  

Randomized, Double-blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of 
using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 17 JUL 2020 
 
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Assessment of treatment efficacy is limited to the last six patients enrolled (the IV-only group), 
as the administration route and dosage for the (hAF) was adjusted after the first four patients (the 
nebulization and IV group). Initially, all patients were being treated with 3ml nebulized hAF and 
only those in the ICU were receiving 3ml IV hAF. However, nebulization was removed after 
concerns about aerosol exposure were raised by the respiratory therapists. In removing this 
administration route from the protocol, it was decided that all enrolled patients, regardless of 
admission location, would receive a standard IV dose of 10ml hAF. The last six enrolled patients 
received this treatment. Four out of those six patients were considered to be responders, with 
decreases in inflammatory biomarker levels (C-reactive protein, lactate dehydrogenase, 
interleukin-6, and d-dimer), while two did only not show reduction in these levels, but saw 
increases. It is unknown if the increases are an adverse reaction to the hAF administration or an 
indicator of severity of disease. Nine of the ten patients have been discharged. One patient (in the 
nebulization and intravenous group) died on hospital day 8. This patient was critically ill and it is 
unlikely that hAF contributed to her illness severity. There were no other reported safety 
concerns, other than the nebulization, addressed above. It appears based on this limited pilot 
sample that patients who responded most favorably to IV hAF were those who were moderately, 
not critically, ill. 
 
Of the 10 patients enrolled, seven were admitted directly to the intensive care unit (ICU). All of 
these patients improved and six were moved to the medical floor. Five patients were discharged 
home and one was discharged to a rehabilitation hospital. One patient was discharged home 
directly from the ICU. Two patients were initially admitted to the medical floor but were moved 
to the ICU due to decompensation. One patient improved and was moved back to the medical 
floor prior to being discharged home, while the other patient died. The final patient was admitted 
to the medical floor and remained there throughout her hospitalization.  
 
All ten patients required oxygen support during their hospital admission. Three patients required 
a nasal cannula or simple mask as their highest level of support, while two were placed on a high 
flow nasal cannula as their highest support. Five patients were intubated during their 
hospitalization. Two of those patients have received a tracheostomy. Both of these patients had 
their trach removed prior to discharge. Of the 9 patients who have been discharged alive, 7 
required home oxygen use.  
 
Primary outcome measures included ventilator-free days and duration of supplemental oxygen 
use. Of the three patients who were mechanically ventilated and ultimately extubated and 
discharged, one was hospitalized for 56 days with 6 days off the ventilator, one was hospitalized 
for 11 days with 5 days off the ventilator, and one was hospitalized for 44 days, received a 
tracheostomy, and had 15 days off the ventilator and the final patient was hospitalized for 38 
days with 28 days off the ventilator. With regard to supplemental oxygen use, two patients were 
entirely on room air at the time of discharge. All other patients were requiring continuous (n=7) 
or intermittent (n=1) supplemental oxygen. 
Secondary outcome measures included the following: 
• Death within 30 days  

Randomized, Double-blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of 
using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 17 JUL 2020 
 
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o N=1 
• ICU free days at day 30 
o 9 of 10 patients were admitted to the ICU. One has died. One patient was 
discharged directly from the ICU. Of the remaining eight patients who were in the 
ICU and moved to the medical floor prior to discharge home, the average ICU-
free days/LOS on the medical floor was 5.9 days (range 1-19 days). Average ICU 
length of stay (n=8) was 17.38 days (range 2-56 days). 
• Hospital length of stay 
o Patients (n=10) had an average hospital length of stay (LOS) of 20.4days (range 
5-56 days).  
• ECMO 
o One patient required treatment with veno-venous ECMO. The patient was on 
ECMO for 41 days. 
• Major adverse cardiac events 
o One patient developed cardiomyopathy, evidenced by worsening tachycardia, 
shock requiring norepinephrine, and elevated creatine kinase. This patient died on 
hospital day 8. 
• Discharge/death 
o Eight patients have been discharged home. One patient was discharged to acute 
inpatient rehabilitation. One was readmitted for pain and numbness and 
subsequently discharged. One patient is deceased.  
• Patient-reported outcomes 
o The final six enrolled patients were consented for patient-reported outcomes. 
These surveys will begin at one-month post-discharge. 
 
Based on the findings of the pilot study, we plan to modify the trial and recruit only patients who 
are considered moderately ill. Patients who are endotracheally intubated on mechanical 
ventilation will not be eligible.  
 
Summarily, merging the COVID-19-related observations and our experience with hAF, we 
hypothesize that systemic administration of hAF may assist in the treatment of this disease in 
moderately ill patients, specifically by reducing inflammation in the lungs. Ideally, this treatment 
could decrease the number of infected patients requiring critical care, thereby impacting patient 
outcomes as well as the socioeconomic burden of this pandemic on precious resources.   
 
5. ELIGIBILITY CRITERIA 
 
Population:  
Hospitalized adult patients with confirmed acute COVID-19 infection. 
 
Inclusion:  
1. Age ≥18 
2. SARS-CoV-2 positivity by RT-PCR test, obtained within 14 days of enrollment 
3. Hospitalized 

Randomized, Double-blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of 
using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 17 JUL 2020 
 
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4. COVID-19 symptomatic (cough, fevers, shortness of breath, and/or sputum production) 
5. Has a room air pulse oximetry of ≤94% and requires supplemental oxygen therapy 
6. Patients of child bearing potential who agree to use acceptable methods of contraception 
for 90 days after last administration of study IP  
7. Patients who are receiving standard of care therapies for COVID-19 that are not FDA 
approved are eligible for this study 
8. Patients must be able to consent to the study (i.e., Glasgow Coma Score of ≥ 14) 
9. Patients are required to have controlled blood pressure of < 160/96 and have a pulse of 
<110 at the time of study drug administration. 
 
Exclusion: 
1. Patients on invasive mechanical ventilation (e.g., endotracheal intubation) 
2. Chronic home oxygen utilization 
3. Clinically significant home use of immunosuppressive medications, including more than 
20mg of steroid (e.g., prednisone) per day, monoclonal antibodies, or chemotherapy 
medications. Patients who are not chronically immune suppressed are eligible for 
participation. Patients who are prescribed steroids, including dexamethasone, for the 
purpose of treating COVID-19 prior to the patient’s study hospital admission will not be 
excluded. 
4. Women who are pregnant, breastfeeding or become pregnant during the study 
5. Patients on non-invasive positive pressure ventilation 
6. Patients on >12 liters per minute via non-rebreather (NRB) or >80% oxygen via high 
flow nasal cannula 
7. Patients who in the opinion of the Investigator has impending respiratory failure, defined 
as requiring rapidly escalating oxygen supplementation 
8. Patients with a hemoglobin < 9 mg/dL 
9. Patients diagnosed with stage 4 or 5 chronic kidney disease (CKD) 
10. Patients with diagnosed with NYHA class 3 or 4 congestive heart failure (CHF) 
11. Patients with a left ventricular assist device (LVAD) 
12. Patients with thromboembolic phenomena 
13. Patients with Type 2 and above heart block 
14. Patients with established positive bacterial blood cultures prior to enrollment 
15. Patients with ongoing pericardial effusion, or ascites 
16. Patients with clinically significant arrhythmia 
17. Patients with liver function tests (ALT or AST) > 3X normal 
18. Patients with untreated HIV infection 
19. Patients diagnosed with end-stage organ disease 
 
Consent:  
Once a patient has been identified as a confirmed positive case of COVID-19, they will be called 
for e-consent. A link to REDCap will be sent and the patient will be asked to access it via their 
personal device to minimize contact between patients and research staff. An outline of the study 
will be presented and the participant will be free to ask questions and carefully consider whether 
or not to participate. They will receive a copy of their signed consent form via email.  

Randomized, Double-blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of 
using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 17 JUL 2020 
 
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6. STUDY DESIGN AND PROCEDURES 
 
1. Patients will be screened via the electronic medical system, and/or noted and communicated 
to the study team by physicians in the units. 
2. Patient will be called for e-consent. 
3. Patients of childbearing potential will receive a pregnancy test   
4. Enrolled patients will be randomized to intervention or control with random permuted blocks 
of 2-4 via sealed envelope or secured electronic randomization tool that will be selected after 
consent. Patients or treating clinicians will not be notified of treatment assignment.   
5. Amniotic fluid will be procured by the Cell Therapy and Regenerative Medicine group here 
at the University of Utah. Product will be delivered, either frozen or thawed, by this group to 
the relevant hospital unit/floor. 
6. After consent, but prior to initial intervention, the following measurements will be collected: 
a. Demographics (age, sex, height, weight, race/ethnicity, study hospital admit date and 
time) 
b. Medical history 
c. Concomitant medications 
d. Confirmation of negative pregnancy test, if applicable 
e. Date of symptom onset 
f. Date of confirmed SARS-CoV-2 positivity by RT-PCR  
g. Vital signs (heart rate, blood pressure, oxygen saturation, respiratory rate, 
temperature) 
a) Patients must have a blood pressure of <160/96 mmHg prior to receiving 
study IP 
b) Patients must have a pulse of <110 beats per minute prior to receiving study 
IP 
h. Glasgow Coma Scale 
a) Patient must have a GCS score of ≥14 prior to consent 
i. Respiratory support modality and settings 
j. Complete blood count with auto differential 
k. Complete metabolic panel 
l. Blood glucose (for patients with diabetes) 
m. Inflammatory biomarkers (interleukin-6, c-reactive protein, d-dimer, lactate 
dehydrogenase) 
n. Results of chest x-ray and/or chest CT, if available. 
7. Patients will receive either 10ml IV hAF or 10ml normal saline (control) each day for 5 
consecutive days. hAF and saline with similar lot numbers will be prepared in order to 
maintain blinding between both clinicians and patients.  
8. For 3 hours following IP administration, patients will be placed on continuous monitoring 
(e.g., pulse oximetry, blood pressure) and monitored for infusion reactions. 
9. Assessments on Days 1-5 will include: 
a. Intervention or control date and time 

Randomized, Double-blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of 
using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 17 JUL 2020 
 
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b. Vital signs (heart rate, blood pressure, oxygen saturation, respiratory rate, 
temperature) 
a) Patient must have a blood pressure of <160/96 mmHg prior to receiving 
study IP 
b) Patient must have a pulse of <110 beats per minute prior to receiving study 
IP 
i. In the event that a patient does not meet blood pressure and/or pulse 
criteria for IP administration, these vital signs will be rechecked every 
hour until they have returned to the necessary range. 
c. Glasgow Coma Scale 
d. Respiratory support modality and settings  
e. Blood glucose (for patients with diabetes) 
f. Results of chest x-ray and/or chest CT, if available. 
g. Concomitant medications 
10. Day 6 (post-intervention) assessment will include: 
a. Vital signs (heart rate, blood pressure, oxygen saturation, respiratory rate, 
temperature) 
b. Glasgow Coma Scale 
c. Respiratory support modality and settings 
d. Complete blood count with auto differential* 
e. Complete metabolic panel* 
f. Blood glucose (for patients with diabetes) 
g. Inflammatory biomarkers (interleukin-6, c-reactive protein, d-dimer, lactate 
dehydrogenase)* 
h. Results of chest x-ray and/or chest CT, if available 
i. Concomitant medications 
*Patients who have been discharged from the hospital prior to Day 6 will be asked to return 
to the hospital or an outpatient clinic for Day 6 lab work. 
11. At ICU discharge (if applicable) and hospital discharge, the following will be gathered: 
a. Intervention or control date and time 
b. Vital signs (heart rate, blood pressure, oxygen saturation, respiratory rate, 
temperature) 
c. Glasgow Coma Scale 
d. Respiratory support modality and settings  
e. Blood glucose (for patients with diabetes) 
f. Results of chest x-ray and/or chest CT, if available.  
12. The following data will be collected following hospital discharge: 
a. Last available results of chest x-ray(s) and/or chest CT(s), if available. 
b. ICU admit and discharge dates and times (if applicable) 
c. Hospital floor admit and discharge dates and times 
d. Dates and times of intubation and extubation (if applicable) 
e. Tracheostomy (if applicable) 
f. ECMO status (and settings, if applicable) 
g. Major adverse cardiac events 

Randomized, Double-blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of 
using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 17 JUL 2020 
 
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h. Discharge date and time 
i. Discharge location 
j. Concomitant medications 
a) Including but not limited to current COVID-19 therapies not approved by 
the FDA, and non-pharmaceutical therapies 
k. Date and time of death (if applicable) 
13. Safety assessments will be performed at 30, 60, 90 and 180 days (+/- 7 days) post-discharge  
a. Safety assessments will include a defined script inquiring about any new or remaining 
symptoms (e.g., shortness of breath), sleep quality, if the patient feels they are back to 
baseline and if they have any positive or negative feedback regarding the IP. Open-
ended questions regarding any additional concerns the participant may have as well as 
a specific question regarding any health events or hospitalizations since the last 
assessment will also be asked. 
b. These assessments will be performed remotely via telephone by study staff. If the 
assessment is positive (i.e., if the patient reports AEs that are determined to be related 
to study drug), a clinician will arrange a telemedicine visit to follow up.  
14. At 1, 3, 6, and 12 months post-discharge, patients will be emailed a REDCap survey link in 
order to complete several surveys: PROMIS measures including Dyspnea Severity, Physical 
Function, Sleep Disturbance, Anxiety, and Depression, as well as the PTSD Checklist (PCL). 
a. If the patient is still hospitalized at any of these time points, respiratory settings and 
details of physical therapy progress will be gathered from the chart instead. 
b. Window: 1 month +/- 7 days, 3/6/12 months +/- 14 days 
15. If a patient is discharged prior to receiving the 5-days of IP administration the patient will 
still be followed for the duration of the study  
 
Primary Outcome: 
1. C-reactive protein levels as assessed prior to and following intervention. 
 
Secondary Outcomes: 
1.   Death within 30 days 
2.   ICU-free days at 30 days  
3.   Hospital length of stay 
4.   Need for invasive mechanical ventilation 
5.   Biomarker levels (interleukin-6, d-dimer, lactate dehydrogenase) 
6.   Need for ECMO 
7.   Major adverse cardiac events 
8.   Patient-reported functional status 
 
7. SAFETY MONITORING 
Safety and tolerability will be evaluated by the investigator from the results of reported 
signs and symptoms, vital sign measurements, and clinical laboratory test results done as 
standard of care during the duration of hospitalization.  More frequent safety evaluations 
may be performed if clinically indicated or at the discretion of the investigator.  
 

Randomized, Double-blinded, Placebo-Controlled Clinical Trial to Determine Safety and Feasibility of 
using an Acellular Sterile Filtered Amniotic Fluid as a Treatment for COVID-19 Patients. 
PI: Craig Selzman, MD 
Version: 17 JUL 2020 
 
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Toxicity will be reported using Common Terminology Criteria for Adverse Events 
(CTCAE) version 5. All AEs will be collected. 
 
Protocol Deviations 
 
A protocol deviation is nonadherence to protocol-specific study procedures or schedules 
that does not involve inclusion/exclusion criteria, primary objective variable criteria, 
and/or GCP guidelines. Deviations are considered minor and do not impact the study. 
 
A protocol violation is any significant divergence from the protocol, i.e., nonadherence 
on the part of the patient, the investigator, or the Sponsor to protocol-specific 
inclusion/exclusion criteria, primary objective variable criteria, and/or GCP guidelines. 
Protocol violations will be identified and recorded by the study site personnel on the 
CRF.  
 
Deviations and violations will be reported to the Principal Investigator and the Sponsor 
and, if necessary (i.e., if the deviation or violation results in an adverse or serious adverse 
event, the DSMB. 
 
Adverse Events 
 
An AE may consist of the following: 
1. A new event which was not pre-existing at initial study drug administration. 
2. A pre-existing event which recurs with increased intensity or increased frequency 
subsequent to study drug administration. 
3. An event which is present at the time of study drug administration which is 
4. exacerbated following initial study drug administration. 
  
 A Serious Adverse Event (SAE) is defined by FDA and NCI as any adverse drug event 
(experience) occurring at any dose that in the opinion of either the investigator or sponsor 
results in any of the following outcomes: 
1. Death 
2. Life-threatening adverse drug experience 
3. Inpatient hospitalization or prolongation of existing hospitalization (for > 24 
hours) 
4. Persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions 
5. Congenital anomaly/birth defect 
6.   Important Medical Event (IME) that may not result in death, be life threatening, 
or require hospitalization may be considered a serious adverse drug experience 
when, based upon medical judgment, it may jeopardize the patient  and may 
require medical or surgical intervention to prevent one of the outcomes listed in 
this definition 
 

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IRB Notification: Events meeting the University of Utah IRB reporting requirements 
(http://www.research.utah.edu/irb/) will be submitted through the IRBs electronic 
reporting system within 10 working days. 
 
 
Staggering of patients (first five [5] subjects) 
 In order to help identify unforeseeable risks, enrollment will be staggered for the first five 
patients. Each patient must complete IP administration followed by window of at least 7-
days before enrollment of the next subject.  
 
 
Safety Criteria for discontinuation of patient enrollment 
• 
Occurrence of 1 or more Grade 3 allergic reactions  
• 
Occurrence of 1 or more  > Grade 3 organ failure (heart, liver, kidney) per CTCAE 
definitions.  
 
Adverse Event Reporting 
 
The site investigator is responsible for evaluating all adverse events at their 
Clinical Center and ensuring that they are properly reported. Adverse events 
that occur during this study will be recorded. The nature of each experience, 
date and time (where appropriate) of onset, outcome, course, and relationship 
to treatment will be documented. 
 
Definition of Adverse Event and Serious Adverse Event 
 
Adverse Event (AE) means any untoward medical occurrence associated with 
the use of an intervention in humans, whether or not considered intervention-
related (21 CFR 312.32 (a)). An event constitutes a disease, a set of related 
signs or symptoms, or a single sign or symptom. 
 
Serious Adverse Event (SAE): A serious adverse event (SAE) for this 
population is an adverse event that: 
 
a) results in death; or 
b) is life-threatening (the patient was, in the view of the site 
investigator, in immediate danger of death from the event as it 
occurred); or 
c) requires inpatient hospitalization or prolongs an existing hospitalization; or 
d) results in persistent or significant disability or incapacity; or 
e) results in congenital anomaly/birth defect; or 
f) is any other event that, based upon appropriate medical judgment, 
may jeopardize the patient’s health and may require medical or 
surgical intervention to prevent one of the other outcomes listed in 
this definition. 

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Classification of an Adverse Event (Relatedness, Severity, and Expectedness) 
 
Relatedness: The suspected relationship between study interventions and any 
adverse event will be determined by the site investigator using the criteria 
below. Relatedness must be assessed by an investigator and may not be 
assessed by a research coordinator. 
 
a) Not Related: The event is clearly related to other factors, such as 
the subject's clinical state, therapeutic interventions, or 
concomitant drugs administered to the subject. 
b) Possibly Related: The event follows compatible temporal 
sequence from the time of beginning the assigned study 
intervention, but could have been produced by other factors such 
as the subject's clinical state, therapeutic interventions, or 
concomitant drugs administered to the subject. 
c) Probably Related: The event follows a reasonable 
temporal sequence from the time of beginning the 
assigned study intervention, and cannot be reasonably 
explained by other factors such as the subject's clinical state, 
therapeutic interventions, or concomitant drugs administered 
to the subject. 
 
Severity: The severity, which is a measure of intensity, of clinical 
adverse events and laboratory abnormalities will be recorded by the site 
investigator and categorized. The following guidelines will be used to 
describe severity. 
 
• 
Grade 1/Mild: The event is asymptomatic or mild symptoms; clinical or 
diagnostic observations only; intervention not indicated.  
• 
Grade 2/Moderate: The event is defined as minimal, local or noninvasive 
intervention indicated; limiting age appropriate instrumental activities of 
daily living (ADL) 
• 
Grade 3/Severe:  The event is medically significant but not immediately 
life-threatening; hospitalization or prolongation of hospitalization 
indicated; disabling; limiting self care ADL 
• 
Grade 4/Life-threatening:  The event requires urgent intervention. 
• 
Grade 5/Death related to AE.  
 
Expectedness of the Event: All adverse events, including serious adverse 
events, will be evaluated as to whether their occurrence was expected or 
unexpected. An AE will be considered unexpected if the nature, severity, or 
frequency of the event is not consistent with the risk information described 
for the study intervention. There are no expected adverse events for IV 

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administered hAF.  
 
Treatment or Action Taken: For each adverse event, the site investigator will 
record whether an intervention was required: 
 
• Medical or surgical procedure 
• Concomitant medication: started, changed, or discontinued 
• Other, specify 
• No action taken 
 
Outcome of Event: Finally, the site investigator will record the clinical 
outcome of each adverse event as follows: 
 
• Death 
• Recovered and the patient returned to baseline status 
• Recovered with permanent sequelae 
• Symptoms persist 
 
Time Period for Adverse Events 
For purposes of this study, events that occur following randomization through 
the Day 180 will be reported as adverse events. Serious adverse events, 
unexpected medically attended events, and new onset chronic illnesses will be 
recorded from randomization through Day 180. Specifically, events that occur 
following informed consent to participate in the study, but prior to actual 
randomization are not adverse events. These should be recorded as baseline 
conditions. 
 
Data Collection Procedures for Adverse Events 
After patient randomization all adverse events (including serious adverse 
events) will be recorded according to relatedness, severity, and expectedness, 
as well as their duration and any treatment prescribed. Any medical condition 
present at the time of randomization, recorded in the patient's baseline history 
at study entry, which remains unchanged or improves (unless the clinician 
feels it is clinically relevant), will not be recorded as an adverse event at 
subsequent evaluations. However, worsening of a medical condition that was 
present at the time of randomization will be considered a new adverse event 
and reported. 
 
Adverse events will be coded using the MedDRA coding vocabulary. Coding 
will be done centrally at the University of Utah Pediatric Department 
Research Enterprise as this requires specific training. 
 
Unanticipated Problems (UP) 
Unanticipated problems (UP) are defined as incidents, experiences, or 

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outcomes that are unexpected, related or possibly related to participation in the 
study, and suggest that the research places subjects at a greater risk of harm 
than was previously known or recognized. The site investigator will report 
unanticipated problems to the Sponsor (CellReGen) within 24 hours of 
becoming aware of the event. A detailed completed report will be required to 
be sent to the (CellReGen) within 3 working days of the event.  
 
In accordance with local IRB requirements, the site investigator may be 
required to report such unanticipated problems to the IRB. In the event that the 
medical monitor believes that such an event warrants emergent suspension of 
enrollment in the trial, they will notify the study investigator and all site 
investigators to cease enrollment in the trial. 
 
Monitoring Serious Adverse Events 
A qualified physician will be designated to fulfill the function of the medical 
monitor for this study. Site investigators and/or research coordinators will 
report serious adverse events to the DSMB and CellReGen within 24 hours of 
becoming aware of the event. A detailed completed report will be required to 
be sent to the DSMB and CellReGen within 3 working days of the event, and 
the medical monitor will assess all serious adverse events reported from site 
investigators. 
 
For each of these serious adverse events, the site investigator will provide 
sufficient medical history and clinical details for a safety assessment to be made 
with regard to continuation of the trial. The medical monitor will sign off on 
each SAE report after review. All SAE reports will be retained at the 
CellReGen. The SAE reporting process may be incorporated into an Electronic 
Data Capture (EDC) System in use for the study. 
 
In the unlikely event that the medical monitor believes an unexpected and 
study-related SAE warrants emergent cessation of enrollment in the trial, 
CellReGen will immediately be consulted. If these individuals concur with the 
judgment of the medical monitor CellReGen will notify the study investigator 
and all site investigators to cease enrollment in the trial. Resumption of 
enrollment will not occur without consent of the CellReGen 
 
In accordance with local IRB requirements, the site investigator may be 
required to report such events to the IRB.  
 
Follow-up of Serious, Unexpected and Related Adverse Events 
All serious, unexpected and related adverse events, that are unresolved at the 
time of the patient's termination from the study, will be followed by the site 
investigators until the events are resolved, patient is lost to follow-up, the 
adverse event is otherwise explained or has stabilized, or 12 months have 

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passed from the time of last study dose. 
 
PATIENT WITHDRAWAL FROM STUDY: 
A patient may withdraw their consent at any time without effect to their care. 
 
DISCONTINUATION OF STUDY DRUG: 
hAF-specific treatment will be discontinued if any of the following occur: 
 
• Recurrent Grade 1 or Grade 2 allergic reactions will be determined by the PI 
• Grade 3 allergic reactions will be cause to discontinue study drug.  
• Patient formally requests to withdraw from the study 
• Patient is discharged from the hospital prior to completing the study drug dose 
regimen 
• Patient experiences >Grade 3 organ failure (heart, liver, kidney) per CTCAE 
definitions.  
 
The study PI, treating clinicians and research staff will monitor closely for the 
above events, as well as any additional adverse events that occur while the 
patient is receiving treatment. Adverse events will be reported immediately 
upon discovery of the event to the PI and assessed for seriousness, relatedness, 
severity, and expectedness. 
 
Any patient who is randomized, and is subsequently withdrawn due either to patient 
choice and/or an adverse event (such as allergic reaction) will continue to be monitored 
per study protocol and per hospital protocol for the duration of their hospitalization. As 
with patients who complete the protocol, these discontinued patients will still have daily 
hemodynamic and respiratory support data collected in our database during 
hospitalization.  Any patients who are withdrawn from the study will continue to receive 
all standard of care monitoring and treatments.  
Allergic reactions, regardless of severity, will be assessed and treated by the Principal 
Investigator based on his or her clinical judgment. This may include use of 
antihistamines, corticosteroids, or albuterol, depending on the patient’s symptoms. 
The DSMB will meet regularly to review adverse events, safety analyses and 
study data and will have access to the actual treatment assignments for each 
group. The DSMB will meet for a kickoff meeting prior to enrollment of the 
first patient, and again following 5 patients, 20 patients, 40 patients, and 60 
patients. They will also meet as needed if any adverse or serious adverse 
events occur.  
 
If study drug is discontinued, we will continue to follow the patient and 
monitor for safety and efficacy endpoints. 
 

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DISCONTINUATION OF STUDY: 
Events used to trigger modification or stopping of the study pending a safety 
investigation include:  
 
• Death of any patient 
• Any SAE as defined in 21 CFR 312.32 
• Three (3) or more of the same Grade 3 or higher AEs (judged by the investigator, 
medical monitor or sponsor), including infusion site reactions 
• One (1) Grade 4 AE 
• One (1) anaphylaxis event 
• Any event which, in the opinion of the investigator, medical monitor or sponsor, 
contraindicates further dosing of additional patients 
• At the discretion of the Data Safety Monitoring Board (DSMB). The 
DSMB will meet regularly to review adverse events, safety analyses, 
and study data. The DSMB will have access to the actual treatment 
assignments for each group. 
 
Any change to the study stopping rules will be reviewed with the FDA.  If the study is 
suspended, it will not be re-opened without FDA approval.  
 
If the study is discontinued (stopped or suspended) all enrolled patients will be followed  
for the planned duration of the study. 
 
 
8. STATISTICAL CONSIDERATIONS 
 
Statistical Methods 
This is a trial with patients randomized to two groups: (1) treatment group with hAF 
administered intravenously (n=30), (2) control group with intravenous administration of a 
saline control (n=30). Both groups will receive standard of care in addition to these 
treatments.  
 
Descriptive statistics, including mean (SD) and median (interquartile range), will be used 
to assess patient characteristics, and clinical and biomarker outcomes. Comparisons will 
be made stratified on ICU vs floor status at enrollment for variables. Categorical 
characteristics will be compared using chi-square test or Fisher exact test. Continuous 
characteristics will be compared using independent samples t-test or Wilcoxon-Mann-
Whitney test. 95% Confidence intervals and p-values will be reported from all 
comparisons. Statistical analyses will be conducted in R and STATA, significance will be 
assessed at the 0.05 level and all tests will be two-tailed. 
 
Safety will be assessed by descriptive reporting of the incidence proportion of 
study-related safety adverse events in each study group, with one-sided 95% 

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binomial exact confidence intervals. No statistical hypothesis test is planned to 
assess safety, which is consistent even with large Phase III trials. The table 
below displays the number of patients, out of 30, experiencing no adverse event 
and the corresponding lower-bound of the 95% exact confidence interval. 
 
Number of Patients with no 
Related Adverse Events 
Number of Patients 
Experiencing a Related 
Adverse Event 
Lower-bound of the 95% 
Exact Binomial Confidence 
Interval for Safety 
30 
0 
90% 
29 
1 
85% 
28 
2 
80% 
27 
3 
76% 
 
If there are 30 patients in the hAF group and if all patients in the hAF 
group complete the study without experiencing an adverse event we will 
be able to state with 95% confidence that the safety of hAF is at least 
90%. 
 
Exploratory outcomes for safety include, but are not limited to, the 
following: 
• Whether the patient experienced any post-randomization AEs 
while on study (regardless of relatedness to study participation) 
• Whether the patient experienced any post-randomization serious 
AEs while on study 
• Whether the patient experienced any post-randomization 
unexpected AEs while on study. 
 
Sample Size Justification 
 
A sample size of n = 30 patients per group (total n = 60) is expected, though 
this may differ slightly because of the randomization procedure. If we are 
unable to enroll 60 patients due to lack of cases, we will expand the study to 
other hospitals. The IRB application shows an enrollment goal of 65, which is 
to allow space to continue enrolling and meet the goal of an n = 60 in the 
event of participant withdrawal. 
 
9. DATA MANAGEMENT 
 
Clinical Site Data Management 
The study team has developed a REDCap database for data collection. REDCap is 
supported by the investigator  
 
Study Monitoring 

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The investigators recognize the importance of ensuring data of excellent quality. 
Study monitoring is critical to this process. Monitoring has been a very effective 
tool for maintaining data quality in previous network studies, and we will utilize 
this process to ensure excellent quality data in the proposed study. The risk-based 
approach to monitoring focuses on oversight activities and preventing or 
mitigating key risks to data quality, as well as to processes critical to human 
subject protection and integrity of the trial or study. 
 
Study monitors must be provided with appropriate access to study materials and 
the medical records for study patients. If the medical records are in electronic 
form, the clinical investigator or an authorized individual must provide any 
assistance necessary to facilitate the study monitor's review of data in the 
electronic medical record. 
 
 
10. PROTECTION OF HUMAN SUBJECTS 
 
Institutional Review Board Approval 
Each clinical center must obtain approval from their respective IRBs prior to 
participating in the study. CellReGen will track IRB approval status at all 
participating centers and will not permit subject enrollment without 
documentation of initial IRB approval and maintenance of that approval 
throughout subsequent years of the project. 
 
Informed Consent 
Informed consent is required because all eligible patients are at least 18 years 
old. Patients who are capable of giving consent and who are alert and 
competent, will be asked, following an appropriate discussion of risks and 
benefits, to give consent to the study.  
 
Potential Risks 
Infection: The University of Utah Cell Therapy and Regenerative Medicine (CellReGen) 
screens the amniotic fluid coming from donors for infectious diseases through medical 
and social history questionnaire, medical record review, and testing of the donor’s blood 
for viruses including HIV, Hepatitis B & C, and others. The CellReGen Medical Director 
reviews the records and test results to determine if the donor meets eligibility 
requirements. Although the risk of transmitting infectious disease is minimal, there is a 
potential for transmission. 
Immune Reaction: You could have an immune reaction to the intravenous amniotic fluid. 
We will monitor you for any signs of such a reaction and provide treatment if needed. 

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Blood Draw: Minor temporary discomfort may be associated with the removal of blood 
by venipuncture. There is a risk of bruising and a very small amount of bleeding 
associated with the blood drawing. There is also a very small risk of infection at the site. 
Whenever possible, blood samples will be gathered when the participant is scheduled for 
routine blood testing or procedures.  
Clinical Data Collection: There is no significant procedural risks associated with review 
of medical records. While there is a potential risk of loss of confidentiality, appropriate 
measures are in place to mitigate this risk.  
Protection Against Potential Risks 
Regarding loss/breach of privacy and confidentiality, all applicable parties (e.g. 
clinical site) will be responsible for ensuring that appropriate data security 
procedures are in place. 
 
Potential Benefits 
We are in an unprecedented global crisis with the spread of the COVID-19 pandemic. The 
data showing that babies born to COVID-19 infected mothers do not have the virus, and 
neither is it found in breastmilk or amniotic fluid, suggests a possible treatment for this 
rampant infection. While it would not cure the virus itself, it has the potential to decrease 
inflammation and fibrosis, thus possibly making critical respiratory treatments less 
necessary. Considering the possible shortage of ventilators, this could be greatly 
beneficial to everyone currently battling this pandemic. 
It cannot be guaranteed that patients themselves would benefit, as this is an experimental 
treatment. However, if our hypothesis is correct, it is possible that COVID-19 infected 
patients would see a reduction of respiratory inflammation and fibrosis. This could result 
in more effective treatment, shorter hospitalization, and less use of critical resources. 
 
11. REGULATORY CONSIDERATIONS 
 
Food and Drug Administration 
This trial is being conducted under an Investigational New Drug 
application. The clinical investigator at each participating site will 
complete a Form FDA 1572, “Statement of Investigator.'' 
 
Health Insurance Portability and Accountability Act 
Data elements collected include the medical record number, date of birth, and 
dates of admission, procedures, discharge and/or death.  
Data elements for race, ethnicity, and sex are also being collected. These 
demographic data are required for Federal reporting purposes to delineate 
patient accrual by race, ethnicity, and gender. 

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Inclusion of Women and Minorities 
There will be no exclusion of patients based on gender, race, or ethnicity. 
 
 
12. AMENDMENTS: IRB AND FDA 
 
Any amendments or administrative changes to an IRB-approved protocol will not be 
initiated without submission of an amendment for IRB review and approval. Any 
amendments to the protocol that significantly affect the safety of participants, the scope 
of the investigation, and/or the scientific quality of the study are required to be submitted 
to the FDA for review. 
 
 
13. FDA ANNUAL REPORTING 
 
As required by the FDA, annual reports will be submitted on this IND application, so 
long as it is active. These annual reports will be submitted to the FDA within 60 days of 
the anniversary of the date that the IND went into effect, per 21 CFR 212.33). Annual 
reports will include the following information: summary of the status of each project 
under this IND, including enrollment goals and actual enrollment numbers as well as a 
summary of any available results from the study; a reporting of adverse events, IND 
safety reports, participant deaths, and participant withdrawals during the last year; 
information about the action of the investigational drug, per information from controlled 
trials; any manufacturing or microbiological changes; the investigational plan for the 
following year; a revised investigational brochure (if applicable); any protocol 
amendments; information on foreign marketing developments (if applicable); as well as a 
log of outstanding FDA communication to which the sponsor expects a reply from the 
FDA. 
 
 
 
 
 
 
 
 
 
 
 

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12. APPENDIX 
 
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patching promotes ischemic rat heart repair. Cell Transplant. 2009;18:1147-59. 
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following pericardiectomy for constrictive pericarditis. J Cardiothorac Surg. 2017;12:6. 
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interferon-γ activated macrophages in vitro. Exp Eye Res. 2006;82:282-92.  
13. Yanxia H Ma, Hui-Kang David, Wan-Soo Kim, Fen Zhang Ph.D. Identification of antiangiogenic 
and anti-inflammatory proteins in human amniotic membrane. Cornea. 2000;19:348-352. 

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14. Mohammadi AA, Seyed Jafari SM, et al. Effect of fresh human amniotic membrane dressing on graft 
take in patients with chronic burn wounds compared with conventional methods. Burns. 2013;39:349-53. 
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composite graft: implications for chronic wound healing. Int Wound J. 2013;10:493–500. 
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cardiovascular system: A review. JAMA Cardiol. Published online March 27, 2020. doi: 
10.1001/jamacardop.2020.1286 
18. Tse G M-K, To K-F, Chan P K-S, et al. Pulmonary pathological features in coronavirus associated 
severe acute respiratory syndrome (SARS). J Clin Pathol. 2004;57(3):260-265. 
19. Tian S, Hu W, Niu L, Liu H, Xu H, Xiao S. Pulmonary pathology of early-phase 2019 novel 
coronavirus (COVID-19) pneumonia in two patients with lung cancer. J Thorac Oncol. Published online 
February 28, 2020. doi: 10.1016/j.jtho.2020.02.010 
20. Mao Y, Pierce J, Singh-Varma A, Boyer M, Kohn J, Reems JA. Processed human amniotic fluid 
retains its antibacterial activity. J Transl Med. 2019;17:1-9. 
21. Pierce J, Jacobson P, Benedetti E, Peterson E, Phibbs J, Preslar A, et al. Collection and 
characterization of amniotic fluid from scheduled C-section deliveries. Cell Tissue Bank. 2016;17(3):413-
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