Tissue Sample Donation Interest Form
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 address *
Please provide your phone number.
Your answer
How do you prefer to be contacted?
What is the donor's first name as recorded on their birth certificate? *
Your answer
What is the donor's middle name as recorded on their birth certificate? *
Write N/A if none
Your answer
What is the donor's last name as recorded on their birth certificate? *
Your answer
What is the donor's sex as recorded on their birth certificate? *
What is the donor's date of birth as recorded on their birth certificate? *
MM
/
DD
/
YYYY
In which city, town, or village was the donor born as recorded on their birth certificate? *
Your answer
In which country was the donor born as recorded on their birth certificate? *
Your answer
Donor's ethnicity (please select all that apply). *
Required
What is the donor's diagnosis? *
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