American Bone Marrow Donor Registry #__________________
CONSENT FORM
I am voluntarily furnishing blood to the American
Bone Marrow Donor Registry (ABMDR) for the purpose of determining my HLA type
for compatibility comparison as a possible marrow or stem cell donor, or I am submitting my
HLA type information for recording in the American
Bone Marrow Donor Registry
files. I
understand the need for and the process involved in marrow or stem cell
donation. I hereby grant the
ABMDR permission to enter my information and
HLA type in its files and to include my HLA type only in Bone Marrow Donors
Worldwide
to be compared to patients’
types in this country and worldwide who are viable candidates for marrow
transplantation. I further understand
that
part of my blood sample may be stored for the sole
purpose of conducting further testing if I am determined to be a possible match
with a
patient. I understand that such
testing would not be performed without my signed consent. I further understand
that my name will be kept
confidential and not released without my
written permission. I understand that
the only side effects from the sample collection might be some bruising or
redness at the site of the needle insertion.
Donor Name (Please Print)
Date / /
Donor Signature Witness Signature
Donor
Information (Confidential)
Street Address Apt.#
City State
Zip
Phone Home(______) Work/Cell: (
)
Fax: (
) __________________________Email:__________________________________________________
D.O.B. / / Sex Spouse First Name
Driver's License: State (_____ ) SS#___________________________________________
Above information used only
for the purpose of locating a donors' forwarding address or for cross-checking
donor records.
Ethnic origin: (may help in patient/donor matching due to the frequent occurrence of
some HLA antigens within certain ethnic groups.)
______Caucasian _______African American _______Native American ________Asian
________Hispanic/Latino
Other (specify) Specific
heritage (e.g French, Jewish, Korean)
_____________________________
Name and address of a relative
or close friend who could contact you if we are unable to reach you.
Name__________________________________________________ Spouse name_________________________
Address________________________________________________________ Apt#________________________
City State Zip________________
Phone Home(______)_____________________________ Work/Cell ( )___________________________
If you are
related to a particular patient, please note relationship and name
Patient Name:
_______________________________________ Relationship_____________________________
PLEASE COMPLETE APPLICATION AND MEDICAL QUESTIONNAIRE
IA0905