DIAN Observational Biospecimen 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.Investigator InformationDate of Request* MM slash DD slash YYYY First Name*Enter the investigator's first name. Last Name*Enter the investigator's last name. Institution*Enter the investigator's institution. Email Address*Enter the investigator's email address. Phone Number*Enter the investigator's phone number.Are you a member of the DIAN Steering Committee?* Yes No Project Title* Project Aim 1*Please provide up to 4 concise aims 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. Project Aim 2 Project Aim 3 Project Aim 4 Source of SupportType of Funding*Please do not list here the DIAN grant or the DIAN PI (Morris); please provide information specific to this request.(Select One)IndustryFederally FundedPrivater FundingInternal or DepartmentalSponsor* Grant Title* Grant Number* Principal Investigator* Faculty MentorIf you are a student, graduate student or fellow, please provide the name of your faculty mentor on this project. Purpose InformationPurpose*What is the purpose of this request? Check all that apply. Current or planned research Preliminary feasibility Data exploration Grant application Journal publication Abstract submission Clinical trial Other Do you have IRB approval?*SelectYesNoPendingAutopsy material w/o genetic implications for offspringIRB Approval Number IRB Approval Date MM slash DD slash YYYY Date Resources Needed MM slash DD slash YYYY Date of Estimated Completion MM slash DD slash YYYY 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). Yes No Diagnostic Categories RequestedSubmit up to 5 individual requests per form submission below: Please be aware that sample sizes may be subject to availability of ADRC materials, resources, and staff. Key: DAT = Dementia of the Alzheimer TypeNumber of Subjects CDRSelect00.5≥ 0.5123Clinical DiagnosisSelect One OptionCognitively NormalUncertain dementiaDAT w/out comorbid conditionsDAT with comorbid conditionsN/AMutation TypeSelectAPPPS1PS2All TypesNon CarrierNeuropathological Diagnosis(based on autopsy)Select One OptionNormal BrainAD pathologyOther (define in additional comments)AD+Other (define in additional comments)N/ANumber of Subjects CDRSelect00.5≥ 0.5123Clinical DiagnosisSelect One OptionCognitively NormalUncertain dementiaDAT w/out comorbid conditionsDAT with comorbid conditionsN/AMutation TypeSelectAPPPS1PS2All TypesNon CarrierNeuropathological Diagnosis(based on autopsy)Select One OptionNormal BrainAD pathologyOther (define in additional comments)AD+Other (define in additional comments)N/ANumber of Subjects CDRSelect00.5≥ 0.5123Clinical DiagnosisSelect One OptionCognitively NormalUncertain dementiaDAT w/out comorbid conditionsDAT with comorbid conditionsN/AMutation TypeSelectAPPPS1PS2All TypesNon CarrierNeuropathological Diagnosis(based on autopsy)Select One OptionNormal BrainAD pathologyOther (define in additional comments)AD+Other (define in additional comments)N/ANumber of Subjects CDRSelect00.5≥ 0.5123Clinical DiagnosisSelect One OptionCognitively NormalUncertain dementiaDAT w/out comorbid conditionsDAT with comorbid conditionsN/AMutation TypeSelectAPPPS1PS2All TypesNon CarrierNeuropathological Diagnosis(based on autopsy)Select One OptionNormal BrainAD pathologyOther (define in additional comments)AD+Other (define in additional comments)N/ANumber of Subjects CDRSelect00.5≥ 0.5123Clinical DiagnosisSelect One OptionCognitively NormalUncertain dementiaDAT w/out comorbid conditionsDAT with comorbid conditionsN/AMutation TypeSelectAPPPS1PS2All TypesNon CarrierNeuropathological Diagnosis(based on autopsy)Select One OptionNormal BrainAD pathologyOther (define in additional comments)AD+Other (define in additional comments)N/AType of Tissue Requested Please specify the following information about your requests above:Type of MaterialSelect OneAntemortem CSFDNADermal FibroblastsCell lines from NCRADPlasma - fastingPlasma - non-fastingSerum - fastingSerum - non-fastingRegion Desired(for brain tissue only) Quantity/Amount DesiredDNA should be noted in µg. CSF/Plasma/Serum in µl. Type of MaterialSelect OneAntemortem CSFDNADermal FibroblastsCell lines from NCRADPlasma - fastingPlasma - non-fastingSerum - fastingSerum - non-fastingRegion Desired(for brain tissue only) Quantity/Amount DesiredDNA should be noted in µg. CSF/Plasma/Serum in µl. If requesting post mortem tissue (frozen brain and paraffin brain sections), please give maximum acceptable PMI: If requesting paraffin brain sections, please give section thickness in µm Sample size determined by: Power Calculations Pilot/Feasibility Study Additional Comments:Specify other details regarding diagnoses and any inclusion/exclusion criteria (e.g. age, race, gender, comorbidities, etc.).HIPAA SectionWill 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. Yes No Please identify who will receive our research materials and for what reason in the text field below: Research Rationale: Please send your research rationale as an attachment to karchc@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 karchc@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 karchc@wustl.edu.File UploadIf 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. Drop files here or Select files Accepted file types: pdf, rtf, txt, doc, docx, Max. file size: 16 MB, Max. files: 3. NameThis field is for validation purposes and should be left unchanged.
