Restricted Use of MACS Specimens

This form is to be completed for MACS participants that have refused consent for stored specimens to be used to establish a cell line, for possible commercial value, or for other reasons that may evolve over the course of the study.

A separate form should be completed for each participant that denies consent. Submit the form to CAMACS (410-955-7587 fax). The repository database files will be flagged immediately to reflect this information.

ID Number:	___ ___ ___ ___ ___

Date:	___ ___ / ___ ___ / ___ ___ ___ ___

m m d d y y y y

The following specimen types from this participant should NOT be distributed:

[mark all that apply]

1. Cells to establish a cell line ___

For Research Use

For Commercial Use

2. Plasma

___	___
3. Serum

___	___
4. Cells (PBMCs)

___	___
5. Existing cell lines

___	___