The NIH Center for Regenerative Medicine

NIH CRM Research Tools

NIH CRM Cell Deposit Form

This document in PDF format (298KB)

The following documents must accompany your submission:

  • Completed deposit form
  • Characterization documentation (see Section 3 below)
  • A copy of protocols used to culture the cell line (see Section 4 below)

Additional pages may be added to expand on answers, marking each response with the question number.

All documents may be submitted either electronically or by mail.

Electronically:
Email to: nihcrm@mail.nih.gov

Subject: Cell Deposit Form

Mail:
NIH Center for Regenerative Medicine
50 South Drive, Room 1139
MSC 8024
Bethesda, MD 20892 USA

SECTION 1: Cell Provider Details

Depositor Name:
Institution/Organization:
Address:
Telephone:
Fax:
E-mail:
Owner of cell line: (if different from depositor)
Name of person with authority to issue the Material Transfer Agreement:
Address:
Telephone:v Fax:
E-mail:

SECTION 2: Cell Line Details

Cell Line Name:
Donor Age:
Donor Gender:
Donor Ethnicity:
Donor Blood Type: A  B  AB  O  Unknown
Normal: (if no, provide disease details)  Yes  No
Cell Type: (if iPSC or iPSC derived cell line, complete the following:)

  • Reprogramming Method: (please specify genes used)
  • Somatic Starting Material:
  • Are donor cells or starting material available?  Yes  No
  • Were the cells derived in a clinically compliant manner?  Yes  No  Unknown
  • Are gene insertions present in the reprogrammed cell?(List methods used to confirm absence or presence of gene insertion events)  Yes  No  Unknown

Passage Number:
Population Doubling Time: (In Recommended Culture Conditions — from Section 4)
Date Derived: (if iPSC derived cell line, include iPSC derivation date and passage number at differentiation)
Genetic Modifications: (if yes, please attach a map or provide a list of the elements in the genetic modifications, how they were created or obtained, and whether the depositing institution/organization has intellectual property rights to these elements.)  Yes  No
Reporters: (if yes, provide details including any elements protected as intellectual property)  Yes  No

SECTION 3 : Characterization Details

Test Name Required Result Testing Performed
Mycoplasma detection (method) Negative Yes No
Sterility assessment Sterile Yes No
Karyotype   Yes No
Identity (STR)   Yes No
Human Virus Testing   Yes No
MAP   Yes No
Bovine pathogens   Yes No
Porcine pathogens   Yes No
In Vivo (in apparent Viruses)   Yes No
28 Day In Vitro   Yes No
Co-cultivation   Yes No
ABO/Rh   Yes No
HLA   Yes No
FACS   Yes No
Embryoid Body   Yes No
Teratoma   Yes No
Whole genome sequencing   Yes No
Epigenic Analysis   Yes No
Other tests   Yes No

Please attach any relevant documentation of the characterization details.

SECTION 4: Culture Conditions

Were the cells co-cultured? (if yes, complete the following 4 questions)  Yes  No

  • Identify supporting cells
  • During derivation process
  • Currently
  • Are the supporting cells commercially available

Attachment Substrate/Matrix
Culture Medium
Passage Reagent
Freezing Medium and Method
Details of critical culture conditions (please attach main culture protocols):

SECTION 5: Consent Information

If redacted consent form is available, please attach.

Is a redacted copy of the consent available?(if yes, please attach)  Yes  No
Do you have access to data that could link the cells back to the donor?  Yes  No
Can the donor be re-contacted?  Yes  No
Check all that apply:

  • For Research Purposes
  • For Commercial Purposes
  • For Therapeutic Purposes

Are there any restrictions on the use of the cell lines? (if yes, provide details)  Yes  No
Is there any available medical information on the donor(s), including infection disease screening? (if yes, provide details)   Yes  No
Is there any available clinical, observational, or diagnostic information about the donor?  Yes  No

SECTION 6: Related Publications

Are there any publications related to this line? If yes, please list:

SECTION 7: Declaration

By submitting this deposit for the NIH Center for Regenerative Medication, I certify that the statements and Assurance herein are true, complete, and accurate to the best of my knowledge.

Signed on behalf of Host Institution (Person responsible e.g., Scientific Director/Department Head)

Date:

Signed by Cell Line Provider: (Person listed in Section 1)

Date:

Name and title of Signatory for Institution/Organization:

  

Address of Institution/Organization: (if different than address in Section 1)

  

This page was last modified on December 17, 2012