DIAN-TU Data and/or Biospecimen Request Form

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

DIAN-TU Biospecimen Resource Request

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.

Project Title & Aims

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

IRB & Other

Request Specifics

Would you like baseline data only or the full dataset?
What type of data are you requesting?
You may select more than one option.
From what cores do you need data?
You may select more than one option.

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 assemble the following documents and e-mail to dian-tudatarequest@wustl.edu:

  • Research Rationale (2 pages max) that includes:
    • Specific aims and hypotheses
      • Description of pilot data for tissue requests
    • Analysis Plan
    • List of variables requested
    • Plan for the protection of the data (e.g., secure cloud storage etc.)
  • IRB or Ethics committee approval (Note: Request can be submitted if IRB review is still pending, however no data will be released until approval is obtained)
  • NIH style biosketch or short CV