DIAN Observational Data Request Form | The Dominantly Inherited Alzheimer Network

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 Information

Date of Request*

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 Support

Type of Funding*

Please do not list here the DIAN grant or the DIAN PI (Morris); please provide information specific to this request.

Sponsor*

Grant Title*

Grant Number*

Principal Investigator*

Faculty Mentor

If you are a student, graduate student or fellow, please provide the name of your faculty mentor on this project.

Purpose Information

Purpose*

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?*

IRB Approval Number

IRB Approval Date

Date Resources Needed

Date of Estimated Completion

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

Request Specifics

If you are requesting imaging data, please indicate the type desired:

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.

Yes
No
Unsure

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).

Yes
No

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.

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 Upload

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.

Drop files here or

Accepted file types: pdf, rtf, txt, doc, docx, Max. file size: 16 MB, Max. files: 3.

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Phone

This field is for validation purposes and should be left unchanged.