Biospecimen Material Transfer Consent Form

Donor Information

Name: Date of Birth: Contact Information:

Description of Biospecimen

Type of Biospecimen: Date of Collection: Additional Details:

Recipient Organization/Researcher

Name: Affiliation/Institution: Contact Information:

Purpose of Transfer

Please describe the purpose of transferring the biospecimen:

Consent Statement

I hereby voluntarily consent to the transfer of my biospecimen described above for the purposes specified. I understand that my participation is voluntary and that I may withdraw my consent at any time. I have had the opportunity to ask questions and have received satisfactory answers.

Donor’s Signature: Date: