International Registry of Werner Syndrome

INTERNATIONAL REGISTRY OF WERNER SYNDROME AND OTHER PROGEROID SYNDROMES

UNIVERSITY OF WASHINGTON, DEPARTMENT OF PATHOLOGY

BOX 357470, SEATTLE, WA 98195-7470 USA

Phone: (206) 616-4225 Fax: (206) 685-8356

BLOOD SAMPLE REQUIREMENTS

Important: Delivery time should not exceed 4 days. Contact Junko Oshima by email or phone (206) 543-5088 to arrange shipment. Do not send samples before contacting us.

Collection (Sterile Techniques)

2 or 3 EDTA (purple top) or sodium heparin tubes of blood

Minimum of 16-20ml of blood

Label each tube with subject’s name, date of birth and collection date

Packaging

Ship at ambient (room) temperature or with refrigerant pack

Ship in waterproof, Styrofoam or other insulating container

International samples:

Include Customs Form (page 2 of this document) or mark package as follows:

Medical research, please rush

Do not freeze

Customs: Human Blood Samples for Diagnostic Purposes

Non-Infectious

No Monetary Value

EIN #916001537

Phone (206) 543-5088

Contact laboratory for pre-addressed packages and blood collection tubes if needed

Shipment

Federal Express or DHL will pick up blood directly from any clinic. Contact us for our third party billing address.

For Federal Express account and internal billing number, contact us. For DHL shipments, receipts are needed for reimbursement.

SHIP SAMPLES PRIORITY TO:

George M. Martin, M.D.

University of Washington

Department of Pathology

1959 N.E. Pacific Street

Room K-543

Box 357470

Seattle, Washington98195-7470

USA

Phone: (206) 543-5088

Notification

Please communicate the airbill number and date of shipment as soon as possible to Junko Oshima at her email address: , fax number: 206-685-8356, or phone number: 206-543-5088 in Seattle. Collect calls will be accepted.

Note to Customs:

Description of the Goods:

Human Blood Samples for Diagnostic Purposes

Non-Infectious

No Monetary Value

EIN #916001537

Contact: Dr. George Martin, Phone (206) 543-5088

SHIPPERS CERTIFICATION FOR NON-HAZARDOUS LIQUIDS/CHEMICALS

This is to certify that the articles/substances of this shipment are properly described by name and they are not listed in the current edition of the IATA Dangerous Goods Regulations (DGR) Alphabetical List of Dangerous Goods nor do they correspond to any of the hazardous classes appearing in DGR section i.e. not restricted. Furthermore the shipper confirms that the goods are in proper condition for air transportation.

Per USDA Guidelines for Importation #1101
Procedures:

A USDA permit will not be required for the importation of material from humans and non-human primates that: (a) are not produced in tissue culture, (b) are not actual zoonotic (affects humans and animals) pathogens, and (c) are not potential zoonotic pathogens. In order to facilitate correct identification of the shipment and to ensure timely delivery, USDA, AHPIS, VS recommends that the following documentation accompany each shipment:

A detailed and accurate description of the material, with species identification.

The material is a human blood sample for diagnostic purposes (a diagnostic test to test for Werner syndrome at the International Registry of Werner Syndrome in Seattle, WA)

A written statement confirming that the material was not obtained from humans or

non-human primates that have been inoculated with or exposed to any livestock* or poultry disease agent exotic to the United States.

This material was not obtained from humans or non-human primates that have been inoculated with or exposed to any livestock or poultry disease agent exotic to the United States.

3. A written statement confirming that the material is not of tissue culture origin.

This material is not of tissue culture origin.

A written statement confirming that the material is not zoonotic.

This material is not zoonotic.

Name and address of the Shipper:Date:

______

MEDICAL RESEARCH: PLEASE RUSH

Ship to: