O
S
P
F
S
D
REGON
TATE
OLICE
ORENSIC
ERVICES
IVISION
M
P
P
– R
S
S
F
ISSING
ERSONS
ROGRAM
EFERENCE
AMPLE
UBMISSION
ORM
THIS PAGE IS REQUIRED FOR EACH FAMILY REFERENCE STANDARD TO BE SUBMITTED
.
4.
FAMILY REFERENCE STANDARD: DONOR INFORMATION
DNA Sample Provided By:
Last
First
Middle
Date of Birth:
Race: ☐African-American
☐Hispanic
☐Asian
☐Caucasian
Sex of Donor: ☐Female ☐Male
☐Native American
☐Other (specify)
Relationship of Donor to Missing Person:
☐Maternally Related ☐Paternally Related
5.
FAMILY REFERENCE STANDARD: CIRCLE BOX INDICATING RELATIONSHIP TO MISSING PERSON
Grandfather
Grandmother
Grandfather
Grandmother
Stepparent*
Aunt
Uncle
Stepparent*
Mother
Father
Aunt
Uncle
Paternal Half Sibling
Cousin
Maternal Half Sibling
Cousin
Female
Male Cousin
Sister
Brother
MISSING
Spouse
Female
Male Cousin
PERSON
Cousin
Cousin
Second
Second
Niece
Nephew
Niece/Nephew
Daughter
Son
Second
Second
Cousin
Cousin
Great Niece
Great
Granddaughter
Grandson
Nephew
Granddaughter
Grandson
The most useful family reference DNA samples are from close blood relatives such as the missing
person’s biological mother, father, children, brothers or sisters. We encourage two or more family
reference samples to be collected. *Stepparents are not appropriate for submission.
6.
FAMILY REFERENCE STANDARD: CONSENT
I understand that the answers provided on this form are correct to the best of my knowledge. I fully understand that my
answers are critical to the process of identifying my missing family member. I freely and voluntarily consent to provide
my sample(s) for DNA analysis, entry into the Relatives of Missing Persons Index of the Combined DNA Index System
(CODIS), and searching against the Unidentified Persons Index of CODIS. I also understand that my DNA profile will be
removed from the CODIS database if my family member is positively identified. I understand that I am not required or
obligated to provide a DNA sample, and that my consent to have a DNA sample taken is knowingly and voluntarily made. I
authorize the collection of this sample(s) for the purpose of identifying my missing family member.
Signature of Donor or Legal Guardian
x
Date:
Originally Adopted:
Issuing Authority:
Revision #: 1
10/23/2017
Operations Manager
Effective Date: 10/23/2017
ALL COPIES OUTSIDE OF POLICY TECH ARE UNCONTROLLED
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