Forms and Documentation

Welcome to the Family Portal for donating to the NIGMS Repository!

Required Paperwork to Return with Kit

Document Description
Submission Form Form that must be submitted for each donor and describes donor's basic information
Informed Consent Form Consent form that must be read completely and signed by each donor
Assent Form Consent form that must be signed by a donor that is between the ages of 7-17 and able to do so. This must be accompanied by the Informed Consent Form.
Clinical Data Elements Form (General) Form that should be submitted for affected individuals only and details this individual's clinical symptoms

Additional Useful Forms

Document Description
Kit Contents Provides a complete list of items found in both pediatric and adult blood and biopsy kits

Blood Kit Instructions
(Domestic)

Provides detailed instructions for collecting, packaging and shipping blood donations from within the United States
Blood Kit Instructions (International) Provides detailed instructions for collecting, packaging, and shipping blood donations internationally
Biopsy Kit Instructions Provides detailed instructions for packaging and shipping biopsy donations, in addition to providing the clinician with instructions on how to perform a skin biopsy
Back-to-Submitter Rights

Form to assign Back-to-Submitter rights to a researcher to receive a single cell line or DNA sample free-of-charge (excluding iPSCs)

Informed Consent for the Transfer of Existing Specimens

Consent form that should be read completely and signed by a donor of a sample that has already been collected and is to be transferred to the NIGMS Repository (e.g. established cell line)


Formularios (Español)

Formulario Descripción
Formulario de Consentimiento Informado Formulario de consentimiento que debe ser leído y firmado por cada donante
Formulario de Asentimiento Formulario que debe utilizarse junto con el documento de consentimiento informado por donante jóven entre 7 y 17 años de edad, y con la capaz de hacerlo
Formato de Solicitud Formulario que debe presentarse para cada donante y describe la información básica del donante
Formulario de Elementos de Datos Clínicos (General) Formulario que debe enviarse solo para individuos afectados y detalla los síntomas clínicos de este individuo
Formulario de Elementos de Datos Clínicos (Por Anomalías Cromosómicas) Formulario que debe enviarse solo para individuos afectados por anomalías cromosómicas y detalla los síntomas clínicos de este individuo
Documento de Consentimiento Informado para la Transferencia de Muestras Existentes Formulario de consentimiento que debe ser leído y firmado por donante de una muestra ya collectada (incluye línea celular)
Instrucciones para el Envío de Biopsias de Tejido Contenido del kit de Coriell para el envío de biopsias de tejido, y instrucciones detalladas del procedimiento.

Disease-Specific Clinical Forms

The following forms should only be submitted for individuals affected by the respective disorder

Document Description
Clinical Data Elements Form (Chromosomal Abnormalities) For individuals affected by a chromosomal abnormality only and details this individual's clinical symptoms
Clinical Data Elements Form (Congenital Muscular Dystrophy CMD) For individuals affected by congenital muscular dystrophy only and details this individual's clinical symptoms
Clinical Data Elements Form (Rett Syndrome; MECP2) For individuals affected by Rett syndrome only and details this individual's clinical symptoms
Clinical Data Elements Form (Smith-Magenis Syndrome) For individuals affected by Smith-Magenis syndrome only and details this individual's clinical symptoms
Clinical Data Elements Form (Propionic Acidemia) For individuals affected by propionic acidemia only and details this individual's clinical symptoms
Clinical Data Elements Form (Pitt-Hopkins Syndrome) For individuals affected by Pitt-Hopkins syndrome only and details this individual's clinical symptoms

If you have any questions that are not answered in this Family Portal, please email us at NIGMS@coriell.org