CHIC DNA Bank Submission Form

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CHIC DNA Bank Submission Form Powered By Docstoc
					                                                             CHIC DNA Repository
                                                     2300 E Nifong Blvd, Columbia, MO 65201-3806
                                                      Phone: (573) 442-0418; Fax: (573) 8785-5073
                                                               www.caninehealthinfo.org
                                                                     Sponsored by




                                    Application for DNA Repository
                                                  (Transfer of MBTCA samples to CHIC)
__________________________________________________________                             __________________________________________________________
Previous application number (if any)                                                   Registration number  AKC  CKC  Other_____________

__________________________________________________________                             __________________________________________________________
Registered name                                                                        Sex                               color

__________________________________________________________                             __________________________________________________________
Breed                                                                                  Date of birth (month-day-year)

__________________________________________________________                             __________________________________________________________
ID number (required)  Tattoo  Microchip                                              Registration # of sire           registration # of dam

__________________________________________________________                             __________________________________________________________
Owner name                                                                             Co-owner name

__________________________________________________________                             __________________________________________________________
Street address                                                                         Owner email

__________________________________________________________                             __________________________________________________________
City                    State/Province   Zip/postal code                               Owner phone



DNA Sample Submission Agreement
I hereby donate, assign, and transfer a DNA sample of the dog named above to the CHIC DNA Repository for research purposes and warrant my authority to do so.
I understand that any future use or distribution of this DNA sample will be within the sole direction and authority of the CHIC DNA Repository. I further understand
that any distribution of samples to researchers will be in a blind format that maintains the anonymity of the dog and owner identities. If a researcher requires further
information regarding an individual dog, owner contact will be initiated through CHIC. My intent in providing this DNA sample is to further research into canine
health issues. I hereby relinquish all rights to, and ownership of, the DNA sample.

________________________________________________________                             _______________________________________________________
Signature of owner/agent                                                              Date


Mission Statement
The CHIC DNA Repository, co-sponsored by the OFA and the AKC/CHF, collects and stores canine DNA samples along with
corresponding genealogic and phenotypic information to facilitate future research and testing aimed at reducing the incidence of
inherited disease in dogs.
Objectives
•    Facilitate more rapid research progress by expediting the sample collection process
•    Provide researchers with optimized family groups needed for research
•    Allow breeders to take advantage of future DNA based disease tests as they become available
•    Foster a team environment between breeders/owners and the research community improving the likelihood
     of genetic discovery
                                                CHIC DNA Repository
                                                          Health Survey

      Owner Name______________________________________Dog Call Name___________________

Has this dog ever been diagnosed with any of the following health issues?
For each section you answer with a yes, please fill out the rest of the section. If you answer no to any section, skip to the next section.

Cancer/Tumors            Yes      No                                    Eye Disorders           Yes       No
    Fibrosarcoma                                                             Cherry eye
    Hemangiosarcoma                                                          Corneal dystrophy
    Leukemia                                                                 Corneal ulcer
    Liver cancer                                                             Distichiasis
    Lymphatic cancer                                                         Dry eye
    Lymphoma                                                                 Entropian/ectropian
    Mammary cancer                                                           Glaucoma
    Mast cell tumor                                                          Juvenile cataracts
    Melanoma                                                                 Optic nerve hypoplasia
    Muscle cancer                                                            Progressive retinal atrophy
    Osteosarcoma                                                             Retinal dysplasia
    Ovarian cancer                                                           Retinal folds
    Pancreatic cancer                                                        Senile cataracts
    Pituitary tumors                                                         Other _______________________________
    Sebaceous gland tumors                                               Ear Disorders          Yes        No
    Squamous cell tumor                                                      Chronic ear infection
    Testicular cancer                                                        Deafness
    Other _______________________________                                    Other _______________________________
Gastrointestinal Disorders  Yes        No                               Neurologic/Muscular Disorders
    Bloat                                                                 Yes  No
    Colitis                                                                  Ataxia
    Inflammatory bowel disease                                               Atlanto axial subluxation
    Megaesophagus                                                            Caudea equina syndrome
    Other _______________________________                                    Epilepsy
Cardiac Disorders           Yes     No                                      Fibrocartilagenous embolis
    Arteriosclerosis                                                         Intervertebral disc disease
    Cardiomyopathy                                                           Lumbo/sacral stenosis
    Congestive heart failure                                                 Narcolepsy
    Degenerative valve disease                                               Spinal demyelination
    Heart murmur                                                             Wobblers syndrome (CVI)
    Mitral valve defect                                                      Other _______________________________
    Pulmonic stenosis                                                    Skin Disorders                Yes      No
    Subaortic stenosis                                                       Alopecia
    Tricuspid valve defect                                                   Autoimmune skin disease
    Other _______________________________                                    Demodectic mange
Respiratory Disorders          Yes     No                                   Food/medicine allergies
    Collapsed trachea                                                        Persistent staph infection
    Elongated soft palate                                                    Seasonal allergies
    Stenotis nares                                                           Sebaceous adenitis
    Other _______________________________                                    Seborrhea
                                                                              Other _______________________________
Liver Disorders         Yes        No                    Kidney Disorders           Yes       No
    Hepatitis                                                 Bladder/kidney stones
    Portosystemic shunts                                      Chronic urinary tract infection
    Other _______________________________                     Ectopic Ureters
Orthopedic Disorders            Yes     No                   Familial kidney disease
    Arthritis                                                 Fanconi syndrome
    Craniomandibular osteopathy                               Renal dysplasia
    Cruciate ligament rupture                                 Other _______________________________
    Elbow dysplasia                                       Reproductive Disorders          Yes      No
    Hip dysplasia                                             Abnormal sperm
    Legg-Calve-Perthes                                        Cryptorchid/monorchid
    Open fontanel                                             Eclampsia
    Osteochondrosis dessicans                                 Failure to conceive
    Panosteitis                                               False pregnancy
    Patellar luxation                                         Genital infection
    Spondylosis                                               Hermaphrodite
    Vertebral anomalies                                       Irregular heat cycle
    Other _______________________________                     Litter resorption
Blood/Lymph Disorders           Yes     No                   Mastitis
    Anemia                                                    Prostatis
    Autoimmune hemolytic anemia                               Pyometria
    Hemophilia                                                Sterility
    Idiopathic Thrombocytopenia                               Testicular atrophy
    Leukemia                                                Other _______________________________
    Phosphofructokinase deficiency                        Temperament Disorders            Yes     No
    Platelet abnormality                                      Aggressive
    vonWillebrand’s disease                                   Fear of noise
    Other _______________________________                     Fear of storms
Endocrinologic Disorders  Yes  No                            Rage syndrome
    Addison’s disease                                         Separation anxiety
    Cushing’s disease                                         Timid
    Diabetes                                                  Other _______________________________
    Hyperthyroid                                          Dental Disorders           Yes       No
    Hypothyroid                                               Missing teeth
    Pancreatitis                                              Overbite
    Pituitary disease                                         Underbite
    Other _______________________________                     Other _______________________________


                                                                   Yes
Has this dog produced puppies? (fill out for sires as well as dams)         No
   If yes, approximately how many?_______________________________________________

           Return this form and a 3-5 generation pedigree to the Canine Health Information Center


                                Canine Health Information Center
                            2300 E Nifong Blvd, Columbia, MO 65201-3806
                              Phone (573) 442-0418; FAX (573) 875-5073

                                     www.caninehealthinfo.org