BRAIN AND TISSUE BANK FOR DEVELOPMENTAL DISORDERS

Department of Pediatrics, Room 10-035 BRB

University of Maryland, Baltimore

655 W. Baltimore St.

Baltimore, MD 21201

(410)-706-1755         (800)-847-1539       FAX: (410)-706-0020

Name     Title

Department 

Institution 

Address   

City  State  Country 

Zip Code   Telephone No.  

Pager No.   Fax No.

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

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)

Tissue(s) requested:

Special requirements:

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Press here to send the information you have entered to the Brain and Tissue Bank.