iPSC & Fibroblast Information Collection Form

The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

c3k4dSaGLBZgza4qdLEhGfBPavbfGdT

Thank you for considering to share samples with NCRAD. Your contribution is an important addition to the research community. Please complete the survey below to provide information about the samples you plan to share. Thank you!

Researcher Name

* must provide value

Institution

* must provide value

Address Line 1 (Street Address)

* must provide value

Address Line 2 (Apt, Ste, Unit)

City

* must provide value

State

* must provide value

Zip / Postal code

* must provide value

Phone number

* must provide value

Email address

* must provide value

Additional Contact Name

Additional Contact Email address

Grant Number(s) that supported iPSC or fibroblast development

* must provide value

Note: We request that investigators submit 3 vials per iPSC and fibroblast line. This ensures the lab has extra vials in the event of a QC measure failure. Sending less than 3 vials could result in additional requests for any vials that fail QC.

Note: If you are depositing fibroblast-derived iPSCs, please send original fibroblast lines in the same shipment.

Are you returning samples generated from NCRAD samples?

* must provide value

Yes

reset

I would like to deposit (check all that apply):

* must provide value

iPSCs

Fibroblasts

iPSC - Number of iPSC lines you want to deposit

1-5

6-10

11-15

16-20

21-25

26-30

31-35

36-40

41-45

46-50

51+

reset

iPSC- Number of lines you would like to deposit

* must provide value

How many vials of each iPSC are you able to deposit?

* must provide value

iPSC- Please select all of the clinical or autopsy diagnoses represented in the iPSCs you would like to deposit
(please select all that apply)

* must provide value

ALS

ALS-FTD

CBD

Control/Unaffected

Dementia unclear of etiology

Down Syndrome

EOAD

FTD

LBD

MCI

PCA

Pick's Disease

PPA

PSP

Vascular Dementia

VBI

Other

iPSC- Diagnosis - Other (Please specify):

* must provide value

iPSC - Number of iPSC lines you want to deposit: 51+ (Please specify)

iPSC- please provide the participant ethnicities represented in the iPSC samples you intend to deposit:
(please select all that apply)

* must provide value

Hispanic or Latino

Not Hispanic or Latino

Unknown

Please select all of the participant races represented in the iPSC samples you intend to deposit
(Please select all that apply)

* must provide value

American Indiana or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

More than One Race

Unknown

Please provide the name and acronym of the study or protocol associated with the samples you intend to deposit at NCRAD:

* must provide value

For this study, please provide the PI name(s) and Grant Number(s) associated with the collection of samples and/or the development of iPSCs and fibroblasts:

* must provide value

Expand

Please provide the cohort description of this study:

* must provide value

Expand

Are there additional studies and cohort descriptions associated with this deposit?

* must provide value

Yes

reset

Please provide the name and acronym of the study or protocol associated with the samples you intend to deposit at NCRAD:

* must provide value

For this study, please provide the PI name(s) and Grant Number(s) associated with the collection of samples and/or the development of iPSCs and fibroblasts:

* must provide value

Expand

Please provide the additional cohort description for this study:

* must provide value

Expand

Are there additional studies and cohort descriptions associated with this deposit?

* must provide value

Yes

reset

Please provide the name and acronym of the study or protocol associated with the samples you intend to deposit at NCRAD:

* must provide value

For this study, please provide the PI name(s) and Grant Number(s) associated with the collection of samples and/or the development of iPSCs and fibroblasts:

* must provide value

Expand

Please provide the additional cohort description for this study:

* must provide value

Expand

Are there additional studies and cohort descriptions associated with this deposit?

* must provide value

Yes

reset

Please provide the name and acronym of the study or protocol associated with the samples you intend to deposit at NCRAD:

* must provide value

For this study, please provide the PI name(s) and Grant Number(s) associated with the collection of samples and/or the development of iPSCs and fibroblasts:

* must provide value

Expand

Please provide the additional cohort description for this study:

* must provide value

Expand

Are there additional studies and cohort descriptions associated with this deposit?

* must provide value

Yes

reset

Please provide the name and acronym of the study or protocol associated with the samples you intend to deposit at NCRAD:

* must provide value

For this study, please provide the PI name(s) and Grant Number(s) associated with the collection of samples and/or the development of iPSCs and fibroblasts:

* must provide value

Expand

Please provide the cohort description for this study:

* must provide value

Expand

iPSCs- Is there a known mutation in any iPSC line you intend to deposit?

* must provide value

Yes

reset

iPSC - Unknown Mutation Information (please select all that apply)
[RETIRED - do not use going forward]

Wild Type

Mutation

Sporadic AD

iPSC - Mutation Type Information (please select all that apply)

Note: Exact mutation information will be required before depositing. Sequencing data for validation will be requested, if available.

APOE4

APP

c9orf72

MAPT

PGRN

PSEN1

PSEN2

TREM2

Other

iPSC - Mutation Type - APOE4
What genotype?

* must provide value

iPSC - Mutation Type - Other (Please specify)

* must provide value

iPSC - Mutation Source

Patient-derived

Genetically engineered

iPSC - Do you have isogenic lines?

Yes

reset

iPSC - Please deposit any isogenic lines, if available.

iPSC - Use of feeders layers?

Yes

reset

iPSC - Media

mTesr1

Tesr2

mTesr E8

mTesr 3D

Nutristem

StemMACS iPS-Brew XF

Unknown

Other

iPSC - Media - Other (Please specify)

iPSC - Substrate

Matrigel

Vitronectin

Laminin

None

Unknown

Other

iPSC - Substrate - Other (Please specify)

iPSC - Freezing media

DMSO

Cryostore

mFreSR

Gibco PSC Cryopreservation

Synth-a-Freeze

Unknown

Other

iPSC - Freezing media - Other (Please specify)

iPSC - Passage number at freeze (range)

1-15

16-20

21-25

26-30

31+

Unknown

iPSC- Please provide the passage number at freeze for iPSCs you are depositing (please provide the range from the lowest passage number you are depositing to the highest)

* must provide value

iPSC - Number of cells frozen per vial

< 500,000

500,000-1,000,000

>1,000,000

Unknown

iPSC - Reprogramming method

* must provide value

Episomal

mRNA

Retroviral

Lentiviral

Sendai Virus

Unknown

Other

iPSC - Reprogramming method - Other (Please specify)

* must provide value

iPSC - Passaging Method

* must provide value

Dispase

Collagenase

Accutase

EDTA

ReLeSR

Unknown

Other

iPSC - Passaging Method - Other (Please specify)

iPSC - CO2 Conditions

5% CO2

Unknown

Other

iPSC - CO2 Conditions - Other (Please specify)

iPSC - O2 Conditions

Atmospheric

Hypoxic

Unknown

iPSC - O2 Conditions - Hypoxic - What % O2?

iPSC - Do you have Mycoplasma testing for iPSCs?

* must provide value

Mycoplasma free

Not tested/unknown

iPSC - Please upload iPSC mycoplasma testing documentation.

Upload file

iPSC - How many requests have you received for your iPSC lines in the last 12 months?

1-5

6-10

11-15

16-20

21-25

26-30

31+

reset

iPSC - Number of requests:

iPSC- Please provide the number of requests you have received for your iPSC lines in the last 12 months:

* must provide value

iPSC - Please upload relevant iPSC protocol(s).

Upload file

iPSC - Do you have an additional iPSC protocol to upload?

Yes

reset

iPSC - Please upload relevant iPSC protocol(s).

Upload file

iPSC - Have any of these iPSC lines been published on?

* must provide value

Yes

Unknown

reset

iPSC - Please provide the PubMed link(s) to publication(s):

Expand

iPSC - Please provide any other relevant information about your iPSCs you would like us to know.

Expand

Fibroblast - Number of fibroblast lines you want to deposit

1-5

6-10

11-15

16-20

21-25

26-30

31-35

36-40

41-45

46-50

51+

reset

Fibroblast - Number of fibroblast lines you want to deposit: 51+ (Please specify)

Fibroblast- Please provide the number of fibroblasts you would like to deposit

* must provide value

Fibroblasts- How many vials of each fibroblast are you able to deposit?

* must provide value

Fibroblasts- Please select all of the clinical or autopsy diagnoses represented in the fibroblasts you intend to deposit
(please select all that apply)

* must provide value

ALS

ALS-FTD

CBD

Control/Unaffected

Dementia unclear of etiology

Down Syndrome

EOAD

FTD

LBD

MCI

PCA

Pick's Disease

PPA

PSP

Vascular Dementia

VBI

Other

Fibroblast- Diagnosis- Other (Please specify):

Fibroblasts- Please provide the participant ethnicities represented in the fibroblasts you intend to deposit:
(please select all that apply)

* must provide value

Hispanic or Latino

Not Hispanic or Latino

Unknown

Fibroblasts- Please provide the participant races represented in the fibroblasts you intend to deposit:
(Please select all that apply)

* must provide value

American Indiana or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

More than One Race

Unknown

Fibroblasts- Please provide the name of the study from which the samples were collected:

* must provide value

Fibroblasts- Is there a known mutation in any fibroblast you intend to deposit?

* must provide value

Yes

reset

Fibroblast - Mutation Info (Fibroblast)

Note: Exact mutation information will be required before depositing.
Please send sequencing data for validation (if available).

Unknown/Wild Type

Mutation

Fibroblast - Mutation Information (Fibroblast)

Note: Exact mutation information will be required before depositing. Please include sequencing primers for validation, if available.

APOE4

APP

c9orf72

MAPT

PGRN

PSEN1

PSEN2

TREM2

Other

Fibroblast - Mutation Type - APOE4
What genotype?

* must provide value

Fibroblast - Mutation Type - Other (Please specify)

* must provide value

Fibroblast - Media

RPMI 1640 + FBS

DMEM + FBS

DMEM/F12 + FBS

Unknown

Other

Fibroblast - Media - Other (Please specify)

Fibroblast - Freezing media

growth medium + DMSO

growth medium + glycerol

Unknown

Other

Freezing media - Other (Please specify)

Fibroblast - Passage number at freeze (range)

1-5

6-10

11-15

16-20

21-25

26+

Unknown

reset

Fibroblasts- Please provide the passage number at freeze for fibroblasts you intend to deposit (please provide the range from the lowest passage number you are depositing to the highest)

* must provide value

Fibroblast - PDL at freeze (range)

1 to 9

10 to 19

20 to 29

30 to 39

40 to 49

50+

Unknown

reset

Fibroblast - Number of cells frozen per vial

< 500,000

500,000-1,000,000

>1,000,000

Unknown

Fibroblast - Passaging Method

Trypsin EDTA

Unknown

Other

Fibroblast - Passaging Method - Other (Please specify)

Fibroblast - CO2 Conditions

5% CO2

Unknown

Other

Fibroblast - CO2 Conditions - Other (Please specify)

Fibroblast - O2 Conditions

Atmospheric

Hypoxic

Unknown

Fibroblast - O2 Conditions - Hypoxic - What % O2?

Fibroblasts - Do you have Mycoplasma testing for fibroblasts?

* must provide value

Mycoplasma free

Not tested/unknown

Fibroblasts - Please upload Fibroblast mycoplasma testing documentation.

Upload file

Fibroblast - How many requests have you received for your fibroblast lines over the last 12 months?

1-5

6-10

11-15

16-20

21-25

26-30

31+

reset

Fibroblast - Number of requests:

Fibroblasts - How many requests have you received for your fibroblasts in the last 12 months?

* must provide value

Fibroblast - Please upload relevant Fibroblast Protocol(s).

Upload file

Fibroblast - Do you have an additional Fibroblast protocol to upload?

Yes

reset

Fibroblast - Please upload relevant Fibroblast protocol(s).

Upload file

Fibroblasts - Have any of these fibroblasts been published on?

* must provide value

Yes

reset

Fibroblasts - Please provide the PubMed link(s) to publication(s):

Expand

Fibroblasts - Please provide any other relevant information about your fibroblasts you would like us to know.

Expand

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.