Genetic Support Services Deposit Form

Any high risk samples will be disposed of immediately without processing

Please complete the following as fully as possible for each sample deposited with ECACC Genetic Support Services.
* denotes obligatory fields

Type of Sample:

Fresh Blood

Frozen PBLs

Frozen Blood for DNA Extraction

Service Required:

Preparation & Storage of PBLs ⁺

EBV Transformation ⁺

DNA Extraction

+ Please Note: ECACC is no longer able to store Depositors samples long term free of charge. Depositors will be charged for storage on a per ampoule per year basis; alternatively, if requested all ampoules will be returned to the depositor at their cost.

A. Contact Details

Depositor/ Principal Investigator*
Title of Study
Contact Name*
E-mail*
Telephone*
Contact Address*
Purchase Order Number

B. Donor Details

Sample Reference / Code*
Date Sample Taken*
Date of Birth

C. Patient Consent
I have obtained consent from the patient for this blood sample to be stored at the ECACC Human Genetic Repository. I have explained that this sample may be transformed into a permanent cell line, which may be made available to qualified investigators for research, teaching or diagnostic purposes. I have explained that DNA extracted from this blood sample may be analysed for research, teaching or diagnostic purposes.

Name of Clinician* (block capitals)
Signature of Clinician*
Name of Institution/Establishment*

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Genetic Support Services Deposit Form

Genetic Support Services Deposit Form

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