SUBMISSION SHEET 



Please Complete Every Item that 

 Applies . 



TO BE FILLED IN BY I MR 

 Date Received / / 



SPECIES: \T\ HUMAN (Go to Item 1) \Y\ OTHER_ 



(Go to Item 8) 



( Specify) 



1. Initials: 



2A. Date of Birth 



/ / 



or Age: 



Mo. Day Year 

 2B. Gestational Age if Amniotic Fluid or Fetus: 



Days Wks. Mos. Yrs. 

 "(Circle One) 



Wks. (Circle One) 



3. Sex: [T] Male [T] Female [3J Ambiguous [4] Not Recorded 



4. A. Race: |T] white |Y| Black [T] Oriental [4] Other 



( Specify) 



B. Ethnic Background if Relevant to the Disorder: 



(Especially Useful for Inborn Errors of Metabolism) 



M 

 PL, 



5. Clinical Phenotype: [T] Clinically Normal [2] Clinically Affected 



[T] No Information 



6. Clinical Manifestations/Diagnosis: (Please List) 



A. 



B. 



C. 



D. 



E. 



7. Source(s) of Clinical Information: (Check One or More) 



|T1 Personal Examination [3] Autopsy Records 



|"2~| Hospital Records {b] Private Physician 



[3J Genetic Clinic Records (7] Other 



[4~1 Specialist's Report (Specify) 



s 



M 

 M 



a 



H 



8. Local Culture/Lab/Biopsy Identification Number: 



9. Type of Sample: \T\ Culture 



if Passages When Submitted 

 Date of Origin / / 



Mo. Day Year 

 Date Submitted / / 



Mo . Day Year 



10. Tissue of Origin [T] Peripheral Blood 



[2~1 Bone Marrow 

 131 Amniotic Fluid 



\2\ Biopsy [3j Blood 



Date Obtained 



/ / 



Mo. 



Day 



Year 



[4] Skin 

 00 Other 



Specify 



18 



