DATA SUBMISSION FORM

Contact Information

Name:
Address:
Phone:
Fax:
Email:
Date Submitted:
Date for Public Release:
Submittor's Published Reference:
Previously Published Reference:


Sequence Change

A: Single base

Base Number:
Base Change:
Amino Acid Change:

B: Small deletion/duplication

Exon containing del/dup:
Intron containing del/dup:
Starting Base Number:
Sequence of del/dup:

C: Large deletion/duplication

Exon:Pro 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Copy Number:

Size of Deletion (Kb):
Enzyme used for Southern Blot:
Other:


Predicted Consequences


Location of mutation


Predicted class of mutation


Amino acid conserved across species


Identification and Validation of the Base Change/Small Dup/Del

Detection Method

Sequence Change Determined

Direct Assay By

How many independent probands carrying this mutation have been identified in your lab?

Expression in vitro LDL-R assay

mRNA Levels

mRNA Size


Regional and Genetic Data

Origin of Patients:
Frequency in Region:

Haplotype of the Chromosome

Indicate any polymorphisms present in the sample.