N AT I O N A L M I S S I N G P E R S O N S DNA University of North Texas Center for Human Identification 3500 Camp Bowie Fort Worth, Texas 76107 1-800-763-3147 www.unthumanid.org [email protected] P R O G R A M Missing Person and Family Reference Sample Information Form N ame of Missing Person: ________________________________________ __________________________________ La st Age when missing: ___________ Missing Person’s Date of Birth: Race: MI Approx. Height: ____________ Approx. Weight: ____________ Physical Identifiers (scars, marks, tattoos, medical devices, etc.) ______________________________ Female Sex of Missing Person: __________ First Male _______________________________________________________ African-American _______________________________________________________ Asian _______________________________________________________ Caucasian Hispanic Are dental records available? Native American Date of Last Contact: Other (Please Specify) ______________________ City/State of Last Contact:____________________________________ Is this reference sample associated with a set of human remains submitted to UNTCHI? Yes Yes No ______________________________________ No If yes, list Agency Name and Case Number: ___________________________________________________________________________________________ Family Member Providing Reference Sample: ______________________________________________ __________________________________ Last Sex of Family Member: Race: Female Male MI Relationship of Family Member to Missing Person: ________________________________________ African-American Asian Note: The most useful family reference DNA samples are from close blood relatives such as the missing persons biological mother, father, children, brothers, or sisters. Submission of maternal relatives of the missing person allows for the analysis of both nuclear and mitochondrial DNA. If you have any questions regarding the selection of family members for reference sampling please call 1-800-763-3147. Caucasian Hispanic Native American Other (Please Specify) __________ First ______________________ CIRCLE BOX BELOW INDICATING RELATIONSHIP TO MISSING PERSON Grandmother Aunt Female Cousin Grandfather Grandmother Mother Uncle Male Cousin Sister Brother Grandfather Father Uncle MISSING PERSON Aunt Female Cousin Spouse Male Cousin Second Cousin Second Cousin Niece Great Niece Nephew Great Nephew Please submit at least one maternal relative. These boxes represent a maternal relative. These boxes represent a maternal relative IF the missing person is female. Version April, 2010 Page 2 of 4 Daughter Granddaughter Son Grandson Granddaughter Grandson