Tissue Sample Donation Interest Form

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This is a survey for the CDCN's Castleman disease biobank (Castlebank). The CDCN will not share the information you provide below with any third party.

Castlebank will collect and store samples from Castleman disease patients, individuals with related diseases (autoimmune, auto-inflammatory, rheumatologic, infectious, or oncologic diseases) and healthy individuals. Each of these is referred to as the "donor" in the below survey. These samples will be made available to qualified researchers world-wide.

If you are the parent of a donor, please provide your information for the first three questions below, and then complete the remaining survey questions with your child's information.

Thank you for your interest in providing samples for Castlebank!

Email *

Please provide your phone number.

How do you prefer to be contacted?

What is the donor's first name as recorded on their birth certificate? *

What is the donor's middle name as recorded on their birth certificate? *

Write N/A if none

What is the donor's last name as recorded on their birth certificate? *

What is the donor's sex as recorded on their birth certificate? *

Female

Male

What is the donor's date of birth as recorded on their birth certificate? *

YYYY

In which city, town, or village was the donor born as recorded on their birth certificate? *

In which country was the donor born as recorded on their birth certificate? *

Donor's ethnicity (please select all that apply). *

American Indian or Alaska Native

Asian

Ashkenazi Jewish

Black or African American

Hispanic/Latino

Native Hawaiian or other Pacific Islander

White

Unknown

No response

Required

What is the donor's diagnosis? *

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