DIAN Observational Data Request Form

Please read the terms and obligations of using DIAN data. By submitting this request, you are acknowledging your acceptance of and willingness to comply with the terms stated.

DIAN Obs Data-Only Requests

Investigator Information

Enter the investigator’s first name.
Enter the investigator’s last name.
Enter the investigator’s institution.
Enter the investigator’s email address.
Enter the investigator’s phone number.
Are you a member of the DIAN Steering Committee?
Please provide up to 4 concise aims below for your project (300 character limit per aim). At least one aim must be provided. Do not indicate: “see attached”. If no aims are entered, your request will not be processed.

Source of Support

Please do not list here the DIAN grant or the DIAN PI (Bateman); please provide information specific to this request.
Please do not list here the DIAN grant or the DIAN PI (Bateman); please provide information specific to this request.
If you are a student, graduate student or fellow, please provide the name of your faculty mentor on this project.

Purpose Information

What is the purpose of this request? Check all that apply.
Purpose
Is it okay to include your data in the DIAN Central Neuroimaging Data Archive?
If you selected “No” to this question, provide your reasons in your submitted Research Rationale (see below).

Request Specifics

If you require novel processing or re-processing of imaging data, limitations or charges may apply.
Have you determined the variables you will need?
If Yes, please specify your variables in your research rationale (see below). If No or Unsure, please contact Chengjie Xiong, PhD (chengjie@wustl.edu) to discuss your research needs.
Do you have a predetermined sample?
If Yes, be prepared to send an electronically readable file including IDs and test dates upon request by the data core staff. If No, please define your criteria for subject selection (e.g. age, CDR, diagnosis, mutation status, presence/absence of other conditions) in your research rationale (see below).
Note: This data request form is one step in the data request process. Ongoing discussions/interactions with the data core staff will also be necessary. This form, and your research rationale submission, should not be considered a “shopping cart” for needed data. Communication with the data core staff will help refine your request based upon your needs and the availability of DIAN materials, resources, and staff.

HIPAA Section

Will you be sharing/sending these materials/data to anyone outside of your immediate research team/lab/office?
Due to HIPAA regulations and Center policies, the approval of this request only covers the use of materials/data by your laboratory/office/staff. If the materials/data are to be shared or analyzed outside your laboratory, please inform us now. Violations of HIPAA regulations can carry significant penalties including fines and prosecution.
Research Rationale:
Please send your research rationale as an attachment to zangela@wustl.edu. Your rationale should include the following information and not exceed 2 pages (references and figures excluded): purpose, background and preliminary data, methods, inclusion and exclusion criteria, analytic plan, and sample size justification.

Biosketch:
Please also send an NIH Biosketch or brief curriculum vitae to zangela@wustl.edu.

Code Access Agreement:
All investigators accessing or receiving DIAN data or tissue must return a signed code access agreement prior to receipt of data/tissue. Please fill out this form and return it to zangela@wustl.edu.

Maximum file size: 16MB

If don’t want to email your files and have them ready, you can upload your Research Rationale, Biosketch and Code Access Agreement files by attaching them to this form. The maximum size limit for all files combined is 16MB.