University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Brain Bank Donor Program
UIC Tissue Repository, Attn: Howard Lipton
Dept. of Microbiology and Immunology (MC790)
E-704 Medical Sciences Building
835 S. Wolcott, Chicago, IL. 60612-7344
Salma Sayeed, Coordinator
Howard Lipton, M.D.
Tibor Valyi-Nagy, M.D., Ph.D.
Directors
(312) 996-5763
- Coordinator office
(312) 355-3581
- Fax
(312) 996-2242, page 2947 - 24-hour pager
Established 2008
MSbbank@uic.edu
MULTIPLE SCLEROSIS GIFT
OF HOPE
RESEARCH DONOR REGISTRATION PACKET
Dear potential donor,
Thank you for your interest in the UIC Multiple Sclerosis Tissue Repository brain donor
program.
Enclosed you will find the Donor Registration forms along with answers to some
frequently asked questions. Please share the registration forms and other information
with your family, especially your next-of-kin. Since their consent is needed immediately
before tissue collection, they share the responsibility for fulfilling your wish to donate.
You may wish to review the registration forms with your physician, as medical history is
collected. This helps us maintain comprehensive information for later correlation with
research studies. Your medical care team should also be informed of your decision.
After reviewing the information provided, if you decide to plan a donation please
complete the attached forms and return them to our office by mail or fax (address and fax
number above). When we receive your completed forms, we will mail you a donor card.
We sincerely appreciate your interest. Tissue donation reflects a strong commitment to
advancing scientific research and endowing hope for the future. We anticipate that tissue
banks like this one can provide researchers with the tools they need to pursue cures for
MS.
Should you have any questions or concerns, please do not hesitate to contact us by phone,
email, fax, or writing at the numbers listed above. In addition, please keep us updated
with any changes to your or your next-of-kin’s contact information.
Sincerely,
Salma Sayeed
Coordinator
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
FREQUENTLY ASKED QUESTIONS ABOUT DONATION
1.
WHAT IS THE PURPOSE OF A BRAIN DONATION? Brain donation is a valuable
gift. One brain provides a basis for studies by numerous researchers throughout the United
States as well as other countries. Although we have improved clinical research methods that
can be performed on living brains, such as genetic studies and imaging techniques,
postmortem tissue best illuminates the biochemistry and pathology of the MS-affected brain.
2.
WHO CAN DONATE? Any legally competent adult can donate their brain to be used for
research after their death, just as they can donate any other organ. Those who may be
incompetent, or otherwise unable to sign, may provisionally donate through their guardian.
However, it is the responsibility of the next-of-kin or guardian to authorize tissue to be
removed for research at the time of death.
3. WHO CANNOT DONATE? We need to know at the time of death if the donor used a
respirator to aid in breathing. Eligibility will be decided on a case-by-case basis. We regret
that organ donors for transplant cannot donate brain tissue to the program because of the use
of respirators for such donations. We also cannot accept donations from patients with highly
contagious or transmissible diseases (such as, but not limited to, tuberculosis, hepatitis, or
Jacob-Creutzfeldt disease). Please let us know at the time of death if the donor was
diagnosed with such a disease. Finally, most medical schools, including UIC, do not accept
body donations from persons who have donated this type of tissue. Donors planning a
medical school donation who are also interested in brain and spinal cord donation should
check with the desired medical school for their policy.
4. WHAT HAPPENS AT THE TIME OF DEATH?
A) At the time of death, the next of kin or a member of the donor’s medical care team
should call the Coordinator or Director. During office hours these numbers are (312)
996-5763 and (312) 996-5754, respectively. After hours call the 24-hour pager at
(312) 996-2242 and page 2947.
B) The next-of-kin MUST give consent by phone BEFORE any tissue may be removed,
even if the donor is registered in our program. It is important to collect tissue as
quickly as possible (usually within 12 hours after death) and before any funeral
preparation. The next-of-kin must be immediately reachable at the time of death to
give this permission.
C) We will arrange for the donor’s body to be transported to UIC Hospital for the
donation procedure at no cost to the donor or family.
D) After the tissue is removed, the body is released to the family for the arranged funeral
services. The family is responsible for transport to a funeral home.
5. MUST THE DONOR BE TRANSPORTED TO OUR FACILITY? Yes. All procedures
are performed at UIC Hospital to ensure that the protocol is carefully followed. We will
provide transportation for the donor’s body to UIC Hospital at no charge, but we do not cover
any funeral or burial transportation expenses.
2
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
6. WILL FUNERAL PLANS HAVE TO CHANGE? After the brain has been removed, the
donor’s body is released to the funeral director or family according to the arrangements
made. An open casket or other traditional funeral arrangement remains possible. The exact
funeral and burial details, however, remain the responsibility of the donor’s survivors or
estate, and no funeral plans (e.g. cremation) can be arranged or carried out by UIC or the
repository.
7. IS THERE ANY COST? The repository pays for the tissue removal and transportation of
the donor’s body to UIC Hospital. Transportation to a funeral home as well as funeral
arrangements and expenses remain the responsibility of the donor and family. Plans must be
made with a funeral home and cannot be arranged or carried out by UIC or the repository (for
example, we cannot arrange to have the donor’s body cremated at UIC).
8. WHO IS NEXT-OF-KIN? The hierarchy of legal relationships is fairly consistent from
state to state, but should be confirmed in the donor’s state of residence. The surviving legal
next-of-kin, according to the Illinois Anatomical Gift Act, is the first to fulfill one of the
following requirements:
(1) Legal agent under power of attorney for health care;
(2) Surrogate decision maker identified under the Health Care Surrogate Act;
(3) Legal guardian;
(4) Spouse (unless divorced or legally separated);
(5) Adult child (if more than one, all must agree);
(6) Parent;
(7) Sibling (if more than one, all must agree);
(8) Adult grandchild;
(9) Close friend;
(10) Executor or administrator (if already appointed)
9. ARE MEDICAL RECORDS OR OTHER CONSENTS NEEDED? The Coordinator will
contact the next-of-kin after the donor’s death. In addition to the next-of-kin’s telephone
consent to remove tissue for research at the time of death, we are required to obtain and keep
on file an original signed informed consent. At this time, we will also send an authorization
for release of the donor’s medical records. This helps us maintain comprehensive
information for later correlation with research studies conducted by scientists. The next-ofkin should sign and return these forms to us. As with all information, these records will be
kept strictly confidential.
10. HOW DO I BECOME A DONOR? Let us know of your wish to donate by
COMPLETING AND RETURNING THE ENCLOSED FORMS. Please review the forms
with your family and physicians, as they will share responsibility for your wishes.
Remember that your next-of-kin must give consent by phone at the time of death. Discussing
your decision with your family and doctors helps avoid confusion about your desire to donate
and makes sure that your endowment for the future is carried out as you have planned.
Please feel free to write, call or email us about any other questions you may have.
3
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
REMINDER: Make sure your family and medical team are aware of your wishes.
Even if you are a registered donor in the tissue repository, your next-of-kin must be willing and available to give
telephone consent for tissue removal at the time of death.
4
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
DONOR REGISTRATION FORM AND MEDICAL HISTORY (PLEASE PRINT OR
TYPE ALL FORMS)
Date: ____________
Person completing form: [ ] donor [ ] next of kin/family member for donor
If donor completing form: Does your next-of-kin live with you? [ ] yes [ ] no
If no, may we contact them with information about their
responsibilities in your donation?
[ ] yes [ ] no
Name of Donor
__________________________________________
Donor’s Home Address
__________________________________________ (*see box p5)
City, State
________________________ Zip Code ___________
Home telephone: (____) ____________________
Cell Phone: (____) ___________
Office phone:
Email: ______________________
(____) ____________________
Current age: ___ Date of Birth: _________ Gender ____ Social Security # _____-___-______
NEXT OF KIN INFORMATION
Name
_____________________________________ Relationship: ____________
Home Address
_____________________________________
City, State
_____________________________________ Zip Code _______________
Home telephone: (____) ___________________ Cell Phone: (____) ___________________
Office phone:
(____) ___________________ Email: ______________________________
Please provide the number where we can reach the next-of-kin for telephone consent at
the time of donor’s death: (____) _______________
Does donor have children? [
] yes [
] no
If yes, how many: _____
Are all children in agreement with this postmortem donation to research?
[ ] yes [ ] no
Is the eldest child the next-of-kin?
[ ] yes [
] no
If no, may we have the contact information for the eldest child as an alternate to the next-ofkin? [If you do not wish to provide this contact information please leave this section blank.]
Eldest Child’s Name ___________________________________
Home Address
___________________________________
City, State
___________________________________ Zip Code ______________
Home telephone:
(____) _________________ Cell Phone: (____) ___________________
Office phone:
(____) _________________ Email: _____________________________
How did you hear about our program? _____________________________________________
5
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
(Internet, MS Chapter, NMSS website, MS support group, NMSS magazine, current donor, etc.)
*If DONOR lives in a Nursing/Assisted Living
Facility please complete:
Date of admission to facility: ________________
*If DONOR is on a Hospice Program
please complete:
Date of admission to hospice: _______________
Name of facility: __________________________
Name of hospice:
Address
Address
________________________
City, State ______________________
City, State
________________________
Zip Code
Zip Code
__________
_____________________
__________
_______________________
Telephone: (____) _________________
Telephone: (____) ___________________
Fax:
Fax:
(____) _________________
(____) ___________________
Contact person (name and number):
Contact person/case manager:
________________________________________
________________________________________
(____) _______________
(____) _______________
MEDICAL HISTORY
Medical diagnoses
Age symptoms Age at
Family history
Relationship of
first appeared diagnosis of disease (yes/no) family member w/disease
MS
Handedness: [
Race:
] Right [
] Left [
] Ambidextrous (both)
_______________________ (Caucasian, Asian, Hispanic, African-American, etc.)
Ethnicity (English/German, etc):
Mother’s side: _____________________ Father’s side: ____________________
Current height: _____ feet _____ inches
Current weight: ________ lbs.
Has donor ever been diagnosed with tuberculosis? [
If yes, when? Age: _____ Year: ______
] yes [
] no
6
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
Treatment given
Current status
Residual
Has the donor, or any blood relatives ever been diagnosed Creutzfeldt-Jakob disease?
[ ] yes [ ] no
If yes, when? Age: _____ Year: ______
Has the donor ever been diagnosed with or suspected to have any of the infectious
communicable diseases in the table below?
Yes/no
If yes, age/year
Treatment given
Current status
Residual
Viral hepatitis B
Viral hepatitis C
HIV/AIDS
Syphilis
Other (specify):
Has the donor had chronic pain disorders/symptoms? If yes please fill in the table below.
(Examples: low back pain, headaches, neuropathy, etc.)
Dates
Disorder/symptoms
Treatment(s)
Has donor been diagnosed with Alzheimer’s disease? [
Any family history of Alzheimer’s?
[
] yes [
] yes [
] no
] no
Has donor been diagnosed with rheumatoid arthritis? [ ] yes [ ] no
Any family history of rheumatoid arthritis?
[ ] yes [ ] no
Has donor participated in any clinical trials? If yes, give the following information:
Date(s)
Name of
trial
Location
Physician
in charge
Name of
medication
Dosage/frequency/duration
MS HISTORY
Type of MS at diagnosis (check one)
___ Relapsing/Remitting
7
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
___ Chronic/Secondary Progressive
___ Primary Progressive
Current type of MS
___ Relapsing/Remitting
___ Chronic/Secondary Progressive (if changed: age ____ / year changed _______)
___ Primary Progressive
(if changed: age ____ / year changed _______)
Physician who gave MS diagnosis
Name
___________________________________
Address
___________________________________
City, State
___________________________________
Office phone:
(____) _________________
What were donor’s earliest
MS symptoms?
Age
Year
Zip Code ______________
How were they treated?
Did they
stop?
(Yes/no)
If yes,
when?
Disability Level
[ ] None of these apply to me.
[ ] I use other forms of assistance. (Fill in blank rows in table below.)
Started to use:
Cane
At age:
Year:
Comments
Walker
Wheelchair or scooter
(some mobility)
Unable to walk at all
Confined to bed
8
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
Symptom
Has
donor
ever
had?
(Yes/no)
If yes at what
sensory
level?
At
age
Year
Treatment
Did these
symptoms
ever go into
remission?
(Yes/no)
If yes
at
what
age?
Year
Optic neuritis
Double vision
Paresthesias
(pins and
needles)
Weakness
Ataxia
(unsteady
walk)
Has donor had optometry or ophthalmologic testing? [ ] yes [ ] no
If yes, results: _______________________________________________________________
What is donor’s current corrected vision? Right eye ___________ Left eye _____________
Medications
[Taken on a regular basis in last 2 years]
Name
Dosage
Dates
Name
Dosage
Were head and spinal cord MRI part of your early diagnostic workup? [
If yes please fill in table below.
Where done
Age
Year
] yes [
Dates
] no
Results or who might we contact for results
9
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
Has donor had any head or spinal cord MRI since? [
If yes please fill in table below.
Where done
Age
Year
] yes [
] no
Results or who might we contact for results
Education
Completed high school
[
] yes [
] no
Attended college
[
] yes [
] no
Completed college
[
] yes [
] no
If no, number of years attended
_______
Completed an associate’s college degree
[
] yes [
] no
If yes, name of degree
_____________________________
Field of study
_____________________________
Completed a post-graduate college degree [
] yes [
] no
If yes, name of degree
______________________________
Field of study
______________________________
Completed a certificate of training
If yes, name/type of certificate
Past medical history
Childhood Diseases: [
] measles [
[
] yes [
] no
______________________________
] mumps [
] chicken pox
Other childhood diseases (specify): ______________________________________________
Occupation
At enrollment:
____________________________________________
If retired, what was your occupation? ____________________________________________
Smoking history
[ ] Never smoked [
[
] Occasional use
[
] Previous regular use [
] Current regular use
] Unknown
If occasional, previous regular, or current regular use:
[ ] Cigarettes [ ] Pipe [ ] Cigar [ ] Other (please specify): _____________________
Age started _______ Number smoked/day _______ How many years? _______
Age stopped (if applicable) _______
Any additional comments: ______________________________________________________
10
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
Alcohol history
[ ] Never drank [
[
] Occasional use
[
] Previous regular use [
] Current regular use
] Unknown
If occasional, previous regular, or current regular use:
[ ] Beer [ ] Wine [ ] Liquor/other (please specify type): _________________________
Age started _______ Number drinks/day _______ How many years? _______
Age stopped (if applicable) _______
Any additional comments: ______________________________________________________
At any time in last five years, did donor believe or was donor told that drinking was excessive?
[ ] yes [ ] no
Drug history
Has donor used any recreational drugs in the last five years? [
[
] Never used [
[
] Unknown
] Occasional use
[
] Previous regular use [
If occasional, previous regular, or current regular use:
[ ] Cannabis [ ] Opium [ ] Coca derivative [
[
] yes [
] no [
] unknown
] Current regular use
] Synthetic Compound
] Other(s) (please specify): __________________________________________________
Age started _______ Number uses/day _______ How many years? _______
Age stopped (if applicable) _______
Any additional comments: ______________________________________________________
Has donor ever had chemotherapy or radiation therapy? [
] yes [
] no
If yes, what kind / for what disease?
___________ / ___________________
Location of therapy (hospital, city, state)
_______________________________
________________________________
Age started _______ Age stopped _______
11
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
MEDICAL TEAM CONTACT INFORMATION
Current neurologist
Current physician
Name
Name / Type
Address
Address
/
City, State
Zip Code
City, State
(
)
Telephone
(
)
Telephone
Current physician
Current physician
/
/
Name / Type
Name / Type
Address
Address
City, State
Zip Code
Zip Code
City, State
(
)
Telephone
(
)
Telephone
Past physician
Past neurologist
Zip Code
/
Name / Type
Name
Address
Address
12
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
City, State
Zip Code
(
)
Telephone
City, State
Zip Code
(
)
Telephone
Hospitals/medical centers where treated
Name
Name
Address
Address
City, State
Zip Code
City, State
Zip Code
(
)
Telephone
(
)
Telephone
Date(s) of treatment: ______________________
Date(s) of treatment: _____________________
PLEASE PROVIDE NAME/ADDRESS BELOW OF ANY OTHER DOCTORS YOU MAY SEE OR
HAVE SEEN IN THE PAST.
13
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
RETURN THIS COPY
This form is NOT the OFFICIAL authorization for collection of postmortem tissue.
Instead it is to be used as a guideline when upon death the next of kin and/or legal representative
is contacted.
The next-of-kin will be contacted at the time of death and be asked to sign the official consent
form.
Name of Donor
For the purpose of scientific research and in the hope of furthering medical knowledge the above
donor requests that their next of kin and/or legal representative sign the OFFICIAL consent for
Collection, Retention and Distribution of Tissue for Research.
The next of kin will be asked to indicate authorization for collection, retention, and distribution of
the following tissues for the purposes of researching psychiatric and neurological diseases:
YES
NO
*Brain
*Blood
*Cerebrospinal fluid (the fluid surrounding the brain)
*Spinal Cord
Eyes
*Trigeminal Ganglia (a nerve around the base of the skull)
Dura matter (outer layer of tissue surrounding the brain)
Hair
Temporal bones (inner ears)
*Pituitary (gland located at the base of the skull)
Other cranial nerves
Do you wish to receive a copy of the neuropathology report (microscopic examination of the
tissue that confirms/negates clinical diagnosis)? [ ] Yes [ ] No
It is further directed that upon the donor’s death, their medical histories be released to the Bank to
provide corollary information critical for scientific studies.
Signatures:
Intended donor:
________________________________
Date _______________
Expected person to sign: ________________________________
(Next-of-kin)
Date _______________
*Indicates the most frequently requested tissue from scientists.
14
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
PLEASE GIVE THIS COPY TO THE NEXT-OF-KIN
This form is NOT the OFFICIAL authorization for collection of postmortem tissue.
Instead it is to be used as a guideline when upon death the next of kin and/or legal representative
is contacted.
The next-of-kin will be contacted at the time of death and be asked to sign the official consent
form.
Name of Donor
For the purpose of scientific research and in the hope of furthering medical knowledge the above
donor requests that their next of kin and/or legal representative sign the OFFICIAL consent for
Collection, Retention and Distribution of Tissue for Research.
The next-of-kin will be asked to indicate authorization for collection, retention, and distribution of
the following tissues for the purposes of researching psychiatric and neurological diseases:
YES
NO
*Brain
*Blood
*Cerebrospinal fluid (the fluid surrounding the brain)
*Spinal Cord
Eyes
*Trigeminal Ganglia (a nerve around the base of the skull)
Dura matter (outer layer of tissue surrounding the brain)
Hair
Temporal bones (inner ears)
*Pituitary (gland located at the base of the skull)
Other cranial nerves
Do you wish to receive a copy of the neuropathology report (microscopic examination of the
tissue that confirms/negates clinical diagnosis)? [ ] Yes [ ] No
It is further directed that upon the donor’s death, their medical histories be released to the Bank to
provide corollary information critical for scientific studies.
Signatures:
Intended donor:
________________________________
Date _______________
Expected person to sign: ________________________________
(Next-of-kin)
Date _______________
*Indicates the most frequently requested tissue from scientists.
15
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
PLEASE CALL, EMAIL, OR USE THIS FORM TO NOTIFY US OF ANY
FUTURE CHANGES
Name of Donor
_______________________________________
Donor’s Home Address
_______________________________________ (*see box below)
City, State
________________________ Zip Code ___________
Home telephone: (____) ____________________
Cell Phone: (____) ___________
Office phone:
Email: ______________________
(____) ____________________
Current age: ___ Date of Birth: _________ Gender ____ Social Security # _____-___-______
NEXT OF KIN INFORMATION
Name
_____________________________________ Relationship: ____________
Home Address
_____________________________________
City, State
_____________________________________ Zip Code _______________
Home telephone: (____) ___________________ Cell Phone: (____) ___________________
Office phone:
(____) ___________________ Email: ______________________________
Please provide the number where we can reach the next-of-kin for telephone consent at
the time of donor’s death: (____) _______________
*If DONOR lives in a Nursing/Assisted Living
Facility please complete:
Date of admission to facility: ________________
*If DONOR is on a Hospice Program
please complete:
Date of admission to hospice: _______________
Name of facility: __________________________
Name of hospice:
Address
Address
________________________
City, State ______________________
City, State
________________________
Zip Code
Zip Code
__________
_____________________
__________
_______________________
Telephone: (____) _________________
Telephone: (____) ___________________
Fax:
Fax:
(____) _________________
(____) ___________________
Contact person (name and number):
Contact person/case manager:
________________________________________
________________________________________
(____) _______________
(____) _______________
Current Physician / Neurologist
__________________________________________________
Address
__________________________________________________
City, State, Zip Code
__________________________________________________
Telephone
(____) _________________
(**If more than one change to physician information please add name, address, telephone on
reverse side)
16
University of Illinois at Chicago
Multiple Sclerosis Tissue Repository
Advancing Research || Improving Treatment
Depts of Neurology and Microbiology-Immunology
835 S. Wolcott (E-704 MSB) Chicago, IL
60612-7344
Phone: (312) 996-5763
Fax: (312) 355-3581
Email: MSbbank@uic.edu 24-hour pager:
(312) 996-2242, page 2947
Donor’s current weight: _____ lbs.
Current height:
_____ feet ____ inches
For any further changes, additions, or comments, please use the reverse side of this form.
17