DNA SHOAH PROJECT

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                                      DNA SHOAH PROJECT
                                     PRIMARY CONTACT DATA

Interview Number

Interview Date (M – D – Y)

Interview Event / Location

Interviewer Name (first / last)

                                                                              Buccal Swab Status
1. Primary Contact Name                                                              Collected Today
                                                                                     Vials sent home
1A. Current Name
                                                                                     Barcode
       1A1.     First

       1A2.     Middle                                                               Future collection
                                                                                     possible
       1A3.     Last                                                                 N/A


1B. Birth Name, only where different than current name, (include maiden name if applicable)

       1B1.     First

       1B2.     Middle

       1B3.     Last

       1B4.      Birth name unknown due to adoption.

1C. Alias, Nicknames, former spellings, other names used

__________________________________________________________________________


2. Gender        Male             Female


3. Status      Survivor    2nd Generation    3rd Generation    Not Applicable



                                              10/23/07 ™
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4. Birth Information

       4A. Birth date (M – D – Y)

               Not Certain         Are you a Holocaust Orphan              Yes  No
                                    (i.e. part of a post-war adoption program, or other familial ambiguity)
       4B. Place of Birth      Not Certain
       4B1. Address

       4B2. City

       4B3. State / Region / Province                              4B4. Country

       4C. Date of immigration to US (M – D – Y)
         Not Certain        Not applicable

5. Current Address

       5A1. Street

       5A2. Street

       5A3. Apartment / Suite / Room

       5A4. City                            5A5. State        5A6. Zip Code

       5A7. Country

6. Phone Numbers

       6A. Home        (            )

       6B. Mobile      (            )

       6C.Other        (            )

              6C1. “Other Phone” is for

7. E-mail Address

8. Barcodes for all individuals reported by this Primary Contact (Excluding self--attached on front)

    Barcode                     Barcode                     Barcode                      Barcode




    Barcode                     Barcode                     Barcode                      Barcode
                                               10/23/07 ™