UK Casino Not On GamstopUK Casino Not On GamstopCasinos Not On GamstopNon Gamstop CasinosNon Gamstop CasinosNon Gamstop Casinos

Back to Previous View

Genetic Study Registration Form

for the
Deposit of Samples at the Human Genetic Cell Bank

Please complete the form below as fully as possible so that we are able to plan the resources required for your project accordingly and provide you with the best advice possible.

Once ECACC receives this form and the project is accepted you will be able to deposit fresh blood samples and frozen lymphocytes for long-term cryopreservation. ECACC will provide you with a project reference code which must be used for all future deposits as part of this project.

In addition to this form the following should also be submitted to ECACC:
(i) A short outline of the proposed project.
(ii) A sample copy of the detailed patient consent form.

* denotes obligatory fields
Title of Project  *
Regional Ethics Committee (REC)
project/reference number
Funding Source
(e.g. MRC, Wellcome Trust)
Date study begins
Duration of study
Please indicate below the disorder(s) you will be depositing and the estimated number of samples to be collected.
Name of Disorder
OMIM No.
Approximate number of samples
Type of sample to be sent Fresh Blood Frozen Peripheral Blood Lymphocytes (PBLs)
Project Requirements

Do you require your samples to be transformed?
  Yes No
 

If yes, do you require your samples to be transformed immediately?
  Yes No
Principal Investigator
Contact Address
Telephone  *
Fax
Email  *
Signature of Principal Investigator


.........................................................................................
Date  *
On receipt of this form ECACC will contact you to set up a Statement of Work.

Back to Previous View  Print