First Name: Last Name: Email: Phone Number:
First Name
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Last Name
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Email
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Phone number
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Name of the Institution: Name of the Division: Name of the Head of Divison: Email of the Head of the Division: Phone number of the head of the Division: Country: City:
Name of the Institution
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Name of the division
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Name of the Head of the Division
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Email of the Head of the Division
Phone number of the Head of the Division:
Country
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Afghanistan Albania Algeria Andorra Angola Antigua & Deps Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia Herzegovina Botswana Brazil Brunei Bulgaria Burkina Burundi Cambodia Cameroon Canada Cape Verde Central African Rep Chad Chile China Colombia Comoros Congo Congo {Democratic Rep} Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland {Republic} Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique {Burma} Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda St Kitts & Nevis St Lucia Saint Vincent & the Grenadines Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe
Do you offer clinical services ?
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Yes No
In what setting does the genetic testing take place?
academic
research
commercial
public health services
academic
research
commercial
public health services
select all that apply
Which clinical domains do you propose?
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Congenital anomalies Developmental disorders Developmental delay Cancer Other Congenital anomalies
Developmental disorders
Developmental delay
Cancer
Other
Select all that may apply
Do you offer laboratory services ?
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Yes No
Is your lab accredited/Certified ?
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Yes No
Which accreditation/Certification ?
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CLIA National certification Other CLIA
National certification
Other
Other
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How many test conducted?
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Max of 5 of the genetic tests the institution can offer
Test/Disease name
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Organism
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Human Microbe
Test Purpose
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Diagnosis Drug Response Monitoring Pre-symptomatic Predictive Prognostic Recurrence Risk Assessment Screening Therapeutic management Diagnosis
Drug Response
Monitoring
Pre-symptomatic
Predictive
Prognostic
Recurrence
Risk Assessment
Screening
Therapeutic management
Category
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Biochemical Genetics Molecular Genetics Cytogenetics Biochemical Genetics
Molecular Genetics
Cytogenetics
Method: Platform: Technology:
Method
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Enzyme assay Immunohistochemistry Protein analysis Protein expression Chromosome breakage studies FISH-interphase FISH-metaphase Fluorescence in situ hybridization Karyotyping Multicolor FISH (M-FISH)/spectral karyotyping Sister chromatid exchange Deletion of homozygosity Linkage analysis Methylation analysis Microsatellite instability testing Mutation scanning of select exons Mutation scanning of the entire coding region RNA analysis Micro-RNA analysis Sequence analysis of select exons Sequence analysisi of the entire coding region Targeted variant analysis Uniparental disomy study
Platform
* must provide value
Chromatography Mass Spectrometry Array-CGH Sanger Sequencing RFLP qPCR MLPA Other
Specimen
* must provide value
Aminiocytes Amniotic fluid Bone marrow Buccal swab Cell culture Cell-free DNA Cerebrospinal fluid Chorionic villi Cord blood Cystic hygroma fluid Dried blood spot card Fetal blood Fibroblasts Fresh tissue Frozen tissue Isolated DNA Paraffin block Peripheral blood Plasma Saliva Serum Skin Sputum Urine white blood cell prep Other Aminiocytes
Amniotic fluid
Bone marrow
Buccal swab
Cell culture
Cell-free DNA
Cerebrospinal fluid
Chorionic villi
Cord blood
Cystic hygroma fluid
Dried blood spot card
Fetal blood
Fibroblasts
Fresh tissue
Frozen tissue
Isolated DNA
Paraffin block
Peripheral blood
Plasma
Saliva
Serum
Skin
Sputum
Urine
white blood cell prep
Other
Select all that may apply
Gene Content
* must provide value
Whole Genome Whole Exome Panel (specify the gene list) Single gene (specify the gene name) Whole Genome
Whole Exome
Panel (specify the gene list)
Single gene (specify the gene name)
Specify the gene list
* must provide value
Specify the gene name
* must provide value
Test/Disease name
* must provide value
Organism
* must provide value
Human Microbe
Test Purpose
* must provide value
Diagnosis Drug Response Monitoring Pre-symptomatic Predictive Prognostic Recurrence Risk Assessment Screening Therapeutic management Diagnosis
Drug Response
Monitoring
Pre-symptomatic
Predictive
Prognostic
Recurrence
Risk Assessment
Screening
Therapeutic management
Category
* must provide value
Biochemical Genetics Molecular Genetics Cytogenetics Biochemical Genetics
Molecular Genetics
Cytogenetics
Method
* must provide value
Enzyme assay Immunohistochemistry Protein analysis Protein expression Chromosome breakage studies FISH-interphase FISH-metaphase Fluorescence in situ hybridization Karyotyping Multicolor FISH (M-FISH)/spectral karyotyping Sister chromatid exchange Deletion of homozygosity Linkage analysis Methylation analysis Microsatellite instability testing Mutation scanning of select exons Mutation scanning of the entire coding region RNA analysis Micro-RNA analysis Sequence analysis of select exons Sequence analysisi of the entire coding region Targeted variant analysis Uniparental disomy study
Platform
* must provide value
Chromatography Mass Spectrometry Array-CGH Sanger Sequencing RFLP qPCR MLPA Other
Specimen
* must provide value
Aminiocytes Amniotic fluid Bone marrow Buccal swab Cell culture Cell-free DNA Cerebrospinal fluid Chorionic villi Cord blood Cystic hygroma fluid Dried blood spot card Fetal blood Fibroblasts Fresh tissue Frozen tissue Isolated DNA Paraffin block Peripheral blood Plasma Saliva Serum Skin Sputum Urine white blood cell prep Other Aminiocytes
Amniotic fluid
Bone marrow
Buccal swab
Cell culture
Cell-free DNA
Cerebrospinal fluid
Chorionic villi
Cord blood
Cystic hygroma fluid
Dried blood spot card
Fetal blood
Fibroblasts
Fresh tissue
Frozen tissue
Isolated DNA
Paraffin block
Peripheral blood
Plasma
Saliva
Serum
Skin
Sputum
Urine
white blood cell prep
Other
Select all that may apply
Gene Content
* must provide value
Whole Genome Whole Exome Panel (specify the gene list) Single gene (specify the gene name) Whole Genome
Whole Exome
Panel (specify the gene list)
Single gene (specify the gene name)
Specify the gene list
* must provide value
Specify the gene name
* must provide value
Test/Disease name
* must provide value
Organism
* must provide value
Human Microbe
Test Purpose
* must provide value
Diagnosis Drug Response Monitoring Pre-symptomatic Predictive Prognostic Recurrence Risk Assessment Screening Therapeutic management Diagnosis
Drug Response
Monitoring
Pre-symptomatic
Predictive
Prognostic
Recurrence
Risk Assessment
Screening
Therapeutic management
Category
* must provide value
Biochemical Genetics Molecular Genetics Cytogenetics Biochemical Genetics
Molecular Genetics
Cytogenetics
Method
* must provide value
Enzyme assay Immunohistochemistry Protein analysis Protein expression Chromosome breakage studies FISH-interphase FISH-metaphase Fluorescence in situ hybridization Karyotyping Multicolor FISH (M-FISH)/spectral karyotyping Sister chromatid exchange Deletion of homozygosity Linkage analysis Methylation analysis Microsatellite instability testing Mutation scanning of select exons Mutation scanning of the entire coding region RNA analysis Micro-RNA analysis Sequence analysis of select exons Sequence analysisi of the entire coding region Targeted variant analysis Uniparental disomy study
Platform
* must provide value
Chromatography Mass Spectrometry Array-CGH Sanger Sequencing RFLP qPCR MLPA Other
Specimen
* must provide value
Aminiocytes Amniotic fluid Bone marrow Buccal swab Cell culture Cell-free DNA Cerebrospinal fluid Chorionic villi Cord blood Cystic hygroma fluid Dried blood spot card Fetal blood Fibroblasts Fresh tissue Frozen tissue Isolated DNA Paraffin block Peripheral blood Plasma Saliva Serum Skin Sputum Urine white blood cell prep Other Aminiocytes
Amniotic fluid
Bone marrow
Buccal swab
Cell culture
Cell-free DNA
Cerebrospinal fluid
Chorionic villi
Cord blood
Cystic hygroma fluid
Dried blood spot card
Fetal blood
Fibroblasts
Fresh tissue
Frozen tissue
Isolated DNA
Paraffin block
Peripheral blood
Plasma
Saliva
Serum
Skin
Sputum
Urine
white blood cell prep
Other
Select all that may apply
Gene Content
* must provide value
Whole Genome Whole Exome Panel (specify the gene list) Single gene (specify the gene name) Whole Genome
Whole Exome
Panel (specify the gene list)
Single gene (specify the gene name)
Specify the gene list
* must provide value
Specify the gene name
* must provide value
Test/Disease name
* must provide value
Organism
* must provide value
Human Microbe
Test Purpose
* must provide value
Diagnosis Drug Response Monitoring Pre-symptomatic Predictive Prognostic Recurrence Risk Assessment Screening Therapeutic management Diagnosis
Drug Response
Monitoring
Pre-symptomatic
Predictive
Prognostic
Recurrence
Risk Assessment
Screening
Therapeutic management
Category
* must provide value
Biochemical Genetics Molecular Genetics Cytogenetics Biochemical Genetics
Molecular Genetics
Cytogenetics
Method
* must provide value
Enzyme assay Immunohistochemistry Protein analysis Protein expression Chromosome breakage studies FISH-interphase FISH-metaphase Fluorescence in situ hybridization Karyotyping Multicolor FISH (M-FISH)/spectral karyotyping Sister chromatid exchange Deletion of homozygosity Linkage analysis Methylation analysis Microsatellite instability testing Mutation scanning of select exons Mutation scanning of the entire coding region RNA analysis Micro-RNA analysis Sequence analysis of select exons Sequence analysisi of the entire coding region Targeted variant analysis Uniparental disomy study
Platform
* must provide value
Chromatography Mass Spectrometry Array-CGH Sanger Sequencing RFLP qPCR MLPA Other
Specimen
* must provide value
Aminiocytes Amniotic fluid Bone marrow Buccal swab Cell culture Cell-free DNA Cerebrospinal fluid Chorionic villi Cord blood Cystic hygroma fluid Dried blood spot card Fetal blood Fibroblasts Fresh tissue Frozen tissue Isolated DNA Paraffin block Peripheral blood Plasma Saliva Serum Skin Sputum Urine white blood cell prep Other Aminiocytes
Amniotic fluid
Bone marrow
Buccal swab
Cell culture
Cell-free DNA
Cerebrospinal fluid
Chorionic villi
Cord blood
Cystic hygroma fluid
Dried blood spot card
Fetal blood
Fibroblasts
Fresh tissue
Frozen tissue
Isolated DNA
Paraffin block
Peripheral blood
Plasma
Saliva
Serum
Skin
Sputum
Urine
white blood cell prep
Other
Select all that may apply
Gene Content
* must provide value
Whole Genome Whole Exome Panel (specify the gene list) Single gene (specify the gene name) Whole Genome
Whole Exome
Panel (specify the gene list)
Single gene (specify the gene name)
Specify the gene list
* must provide value
Specify the gene name
* must provide value
Test/Disease name
* must provide value
Organism
* must provide value
Human Microbe
Test Purpose
* must provide value
Diagnosis Drug Response Monitoring Pre-symptomatic Predictive Prognostic Recurrence Risk Assessment Screening Therapeutic management Diagnosis
Drug Response
Monitoring
Pre-symptomatic
Predictive
Prognostic
Recurrence
Risk Assessment
Screening
Therapeutic management
Category
* must provide value
Biochemical Genetics Molecular Genetics Cytogenetics Biochemical Genetics
Molecular Genetics
Cytogenetics
Method
* must provide value
Enzyme assay Immunohistochemistry Protein analysis Protein expression Chromosome breakage studies FISH-interphase FISH-metaphase Fluorescence in situ hybridization Karyotyping Multicolor FISH (M-FISH)/spectral karyotyping Sister chromatid exchange Deletion of homozygosity Linkage analysis Methylation analysis Microsatellite instability testing Mutation scanning of select exons Mutation scanning of the entire coding region RNA analysis Micro-RNA analysis Sequence analysis of select exons Sequence analysisi of the entire coding region Targeted variant analysis Uniparental disomy study
Platform
* must provide value
Chromatography Mass Spectrometry Array-CGH Sanger Sequencing RFLP qPCR MLPA Other
Specimen
* must provide value
Aminiocytes Amniotic fluid Bone marrow Buccal swab Cell culture Cell-free DNA Cerebrospinal fluid Chorionic villi Cord blood Cystic hygroma fluid Dried blood spot card Fetal blood Fibroblasts Fresh tissue Frozen tissue Isolated DNA Paraffin block Peripheral blood Plasma Saliva Serum Skin Sputum Urine white blood cell prep Other Aminiocytes
Amniotic fluid
Bone marrow
Buccal swab
Cell culture
Cell-free DNA
Cerebrospinal fluid
Chorionic villi
Cord blood
Cystic hygroma fluid
Dried blood spot card
Fetal blood
Fibroblasts
Fresh tissue
Frozen tissue
Isolated DNA
Paraffin block
Peripheral blood
Plasma
Saliva
Serum
Skin
Sputum
Urine
white blood cell prep
Other
Select all that may apply
Gene Content
* must provide value
Whole Genome Whole Exome Panel (specify the gene list) Single gene (specify the gene name) Whole Genome
Whole Exome
Panel (specify the gene list)
Single gene (specify the gene name)
Specify the gene list
* must provide value
Specify the gene name
* must provide value
Submit
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