FBI Forms — Body Donation Investigation

End User First Name

End User Last Name

End User Organization

Address 1

Address 2

City

State

Country

ZIP/Postal Code

Primary Telephone Number

Secondary Telephone Number

E-Mail Address:

1. From which company(s) did you/your organization purchase or lease human anatomical material? Select all that apply.

Biological Resource Center of Illinois (BRCIL)

Biological Resource Center (Phoenix, Arizona)

Anatomical Service, Inc. (ASI)

Arthroscopy Association of North America

International Biological, Inc.

2. Did you/your organization receive any literature via mail, e-mail, or fax about the company and its products or services? Select all that apply.

Yes (Mail)

Yes (E-mail)

Yes (Fax)

No

3. Are/were there any contracts or purchase agreements between you/your organization and the company?

Yes
No

4. If you answered yes to question 3, how were these documents exchanged (mail, e-mail, fax, etc.)?

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5. Did any contract, purchase agreement, or other documentation claim that all the human anatomical material had been properly and legally consented?

Yes
No

6. Did the provider make specific claims about negative serology results?

Yes
No

7. Did the provider make any claims of general non-infectiousness with regard to the human anatomical material?

Yes
No

8. If you answered yes to questions 6 or 7, please explain.

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9. How did you receive the human anatomical material? Hand delivered by provider company, shipped air freight (provide company name), shipped ground (USPS/FedEx/UPS/Other), etc.

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10. Would you like someone from the FBI to contact you to discuss this issue further? If yes, please ensure you have all invoices, contracts, lists of human anatomical material, and other information related to this matter available for reference.

Yes
No

Privacy Act Statement

The FBI is authorized to collect the information on this form by one or more of the following provisions: Title 28, United States Code, sections 533 and 534; Title 28, Code of Federal Regulations, section 0.85; and the Attorney General Guidelines for Victim and Witness Assistance. The information requested will assist the FBI in providing you with assistance to which crime victims are entitled under federal law. You do not have to provide the requested information; however, failure to do so may hinder the FBI in providing you with crime victim assistance. The information collected on this form is protected by the Privacy Act of 1974, as amended, Title 5, United States Code section 552a, and is maintained in the FBI’s Central Records System, DOJ/FBI-002, a description of which was published in the Federal Register at 63 Fed. Reg. 8671 (Feb. 20, 1998) and which may be viewed at www.justice.gov/opcl/privacyact.html#doj.

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Sections

Body Donation Investigation - End User Questionnaire