Mass Fatality Incidents: A Guide for Forensic Identification

MASS FATALITY INCIDENTS: A GUIDE FOR HUMAN FORENSIC IDENTIFICATIONSample Donor Consent FormNote: This form is a sample only based on forms developed by the Armed Forces for the DOD DNA registry.The law concerning DNA samples varies across jurisdictions. Modify forms accordingly.PRIVACY ACT STATEMENT/STATEMENT OF CONSENTAUTHORITY:PRINCIPAL PURPOSE(S):ROUTINE USE(S):DISCLOSURE:5 U.S.C. 301; 10 U.S.C. 3012; Pub. L. 91–121, Section 404 (a) (2); andmemo dated 16 December 1991 from Deputy Secretary of Defense,Subject: DOD DNA Registry. Also under authority of 10 U.S.C. 176and 177, Pub. L. 94–361; DOD Directive 5154.23; and, if SocialSecurity number collected, EO 9397.Establish a DNA reference specimen repository and database ofinformation from kindred family members of unaccounted for/unidentifiedservice members or other individuals who need to be identified.DNA will be extracted from either vials of blood, dried blood,and/or oral swabs, and will be used in identifying human remains.None.Voluntary. Failure to provide reference sample or information mayrender DNA identification impossible.STATEMENT OF CONSENTThe above answers are correct to the best of my knowledge and belief, and I understand that myanswers are important in determining my kindred family relationship to an unaccounted for servicemember or other unaccounted for individual. I have also read the Privacy Act statement above.Realizing that nuclear or mitochondrial deoxyribonucleic acid (DNA) may be extracted from myblood and used in the identification of a kindred family member, I agree to donate my blood, tohave my DNA analyzed if necessary, and to have my name and other relevant typing informationplaced in a confidential registry or database for identification and statistical analysis.I am voluntarily donating tubes of blood via venipuncture, or if impracticable, consenting to the fingerstickmethod of securing a small amount of blood, or allowing the taking of an oral swab.I have not received a blood transfusion within the last 3 months (if you have received a transfusion,please wait for a period of 90 days following the transfusion before providing the referencesample).I consent to the Armed Forces using the information and specimens for the identification of anyunaccounted for family members.______________________________ ________________________________ _________________Signature of Donor Printed Name of Donor DateVERIFICATION OF DONOR IDENTIFICATION AND SPECIMEN COLLECTIONI have verified from a photo ID that the blood or other biological specimen collected has come fromthe above-stated donor, and have confirmed the donor’s name and/or Social Security numberplaced on the collection tubes.______________________________ ________________________________ _________________Signature of Collector Printed Name of Collector Date65