Please complete the following, as fully as possible, for each sample deposited. This form should accompany each sample deposited to the Human Genetic Cell Bank. The phenotype of the donor must be included.
* denotes obligatory fields
Type of sample
Fresh Blood
Frozen Peripheral Blood Lymphocytes (PBLs)
Is sample to be transformed?
Yes
No
A. Donor Details
Your Reference No./Code
*
Date sample taken
*
Date of Birth
*
Surname (optional)
Forenames (optional)
B. Clinical Details
Phenotypic Sex
Male
Female
Ambiguous
Race
Caucasion
Black
Asiatic Indian
Oriental
Other (please specify)
Clinical Phenotype
abnormal or affected
normal or unaffected
not known
Diagnosis
OMIM No.
Is disease
sporadic
familial
If familial, is inheritance pattern
sex linked
autosomal dominant
autosomal recessive
mitochondrial
complex
Other relevant clinical details
Karyotype (Paris nomenclature)
Balanced
Unbalanced
Have any other samples from this patient/family been deposited with ECACC?
Yes
No
If YES please give ECACC number and supply a detailed pedigree:
Pedigree Supplied?
Yes
No
Literature reference
C. Sample Access & Patient Consent
Do you wish the cell line to be added to the ECACC catalogue?
Yes, I hereby grant permission for this sample to be stored at the ECACC Human Genetic Cell Bank for distribution to the scientific community for research, teaching, therapeutic or diagnostic purposes.
No
If YES do you wish to delay access to researchers?
Yes
No
This sample is part of the registered project:
Title of Study
*
Principal Investigator/Depositor
*
I have obtained consent from the patient for this blood sample to be stored at the ECACC Human Genetic Cell Bank. I have explained that this sample may be transformed into a permanent cell line, which will be available to qualified investigators for research, teaching, therapeutic and diagnostic purposes.
