DIAN-TU Data and/or Biospecimen Request Form | The Dominantly Inherited Alzheimer Network

Please read the terms and obligations of using DIAN-TU 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.

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 (Bateman); 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 or Ethics approval?*

IRB/Ethics Approval Number

IRB/Ethics Approval Date

Date Resources Needed

Date of Estimated Completion

Request Specifics

Would you like baseline data only or the full dataset?

Baseline data only
Baseline and post-randomization data

What type of data are you requesting?

You may select more than one option.

Processed data
Raw imaging files
Tissue or biofluid

From what cores do you need data?

You may select more than one option.

Clinical Core (demographics, CDR, MMSE, etc.)
Cognition Core (paper and pencil tests, computerized measures, etc.)
Imaging Core (PET, MRI, etc.)
Biomarker Core (CSF etc.)
Genetics Core (APOE, Mutation information etc.)
Neuropathology Core (Neuropathologic assessment and diagnosis)

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

Research Rationale: Please assemble the following documents and e-mail to dian-tudatarequest@wustl.edu or upload in the File Upload box below:

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

File Upload

If don't want to email your files and have them ready, you can upload your Research Rationale, IRB or Ethics Committee approval and NIH style biosketch or short CV files by attaching them to this form. The maximum size limit for all files combined is 32MB. File formats that are acceptable are: pdf, rtf, doc and docx. No more than 4 files may be uploaded.

Drop files here or

Accepted file types: pdf, rtf, txt, doc, docx, Max. file size: 32 MB, Max. files: 4.

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Name

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