BRAIN AND TISSUE BANK FOR DEVELOPMENTAL DISORDERS

Department of Pediatrics, Room 13-013 BRB
University of Maryland, Baltimore
655 W. Baltimore Street
Baltimore, MD 21201
(410)-706-1755             (800)-847-1539           FAX: (410)-706-2128
e-mail: btbumab@umaryland.edu
Tissue Request Form
 
Name __________________________________________Title________________________________

Department ________________________________Institution_________________________________

Address ___________________________________________________________________________

City_________________ State_____________ Country ___________Zip Code _________

Phone____________Pager _____________ Fax_____________email____________________________

Have you ever requested tissues from the Brain and Tissue Bank? ____Yes ____No   

Title of your project ___________________________________________________________________

Source of funding (specify NIH institute, if appropriate) _______________________________________________

Goals of your research - (Please summarize on a separate page.)

Specifications of Tissue Required

Category of tissue requested:   ____Affected (please enter Disorder below) ____Unaffected (control)

Name of Disorder _____________________________________________________________________

If known, please specify UMB# (s)_______________________________________________________

Age limits___________________      Sex ____________      Race_________________

____Frozen  _____Fixed _____Fresh      Post Mortem Interval(hrs)_____________

Control cases (quantity)_____  Disorder cases (quantity)_____  Amount of tissue (g/vol)_____________

Will you accept HBSAG positive tissue? ____Yes ____No

Will you accept tissue untested for biologic pathogens? ____Yes____No

Tissue(s) requested:___________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Special requirements:_________________________________________________________________

___________________________________________________________________________________

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