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Indiana Biobank Budget Request Survey

Thank you for your interest in the Indiana Biobank. Please complete the following questions for us to develop your budget. Please contact Whitney Jaunzemis at wbobb@iu.edu if you have any questions.

Last Name

* must provide value

First Name

* must provide value

Institution

* must provide value

Phone

* must provide value

Is there a contact for the project (different from the PI)?

* must provide value

Yes No

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Last Name

First Name

Phone

What is the funding source for this project (i.e. NIH RFA, non-profit, etc.)

Do you have your own IRB protocol?

Yes

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If no, do you plan on utilizing the Indiana Biobank protocol?

Yes

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If yes, do you need recruitment support?

Yes

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If yes, what is the participant recruitment criteria for your study?

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Who is the program officer?

What is the full name of the study?

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What is the study abbreviation? (If applicable)

Is this study already active?

Yes No

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What is the proposed start date (with Indiana Biobank)?

* must provide value

M-D-Y

What is the study duration?

* must provide value

How many sites will enroll?

Of these sites, how many will be located at IU?

How many sites are outside the United States?

Where are the International sites located?

How many participants will be enrolled total?

What is the participant recruitment criteria for your study?

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Is your study longitudinal?

(Indiana Biobank protocol cannot be used for these studies)

Yes

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Please fill in the number of participants expected to have a visit in each year:
Visit	Year 1	Year 2	Year 3	Year 4	Year 5
Baseline
Total

Including baseline, how many visits will be conducted per participant?

What is the time frame for the visits?

Monthly

Every 6 Months

Annual

Other

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Are the same specimens collected at every visit?

Yes

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What is the visit schedule?

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Please fill in the names of the visits in the "Visit" column (Baseline, V1, V2, etc), and the number of participants expected to have a visit in each year in the "Years 1-5" columns:

Visit	Year 1	Year 2	Year 3	Year 4	Year 5






Total

What sample types will be collected?

* must provide value

DNA (whole blood)

DNA (buffy coat-often from same EDTA tube as plasma)

DNA (saliva)

DNA (transferred aliquots)

miRNA (whole blood PAXgene blood tubes)

Total RNA (whole blood PAXgene blood tubes)

Plasma (processed from EDTA blood tubes)

Serum (processed from serum blood tubes)

Whole Blood to store

CSF

Urine

Saliva

Fecal

PBMC (whole blood NaHep tubes)

Other

How much blood for DNA is expected to be collected from each participant at each visit?

How many buffy coat samples are expected from each participant at each visit?

How many buffy coat aliquots will be transferred to Indiana Biobank?

All collected

Other

How many saliva samples (for DNA) are expected from each participant at each visit?

How frequently will DNA aliquots be transferred?

What size aliquots will be transferred to Indiana Biobank?

Can Indiana Biobank store and share any residual DNA?

Yes

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How much blood for RNA is expected to be collected from each participant at each visit?

How much blood for plasma is expected to be collected from each participant at each visit?

What is the aliquot size?

1500 uL (1.5 mL)

1000 uL (1.0 mL)

500 uL (0.5 mL)

Other

How many plasma aliquots will be transferred to Indiana Biobank?

All collected

Other

Please provide details on aliquots to be transferred

How much blood for serum is expected to be collected from each participant at each visit?

What is the aliquot size?

1500 uL (1.5 mL)

1000 uL (1.0 mL)

500 uL (0.5 mL)

Other

How many serum aliquots will be transferred to Indiana Biobank?

All collected

Other

Please provide details on aliquots to be transferred

How much blood to send as unprocessed/frozen whole blood is expected to be collected from each participant at each visit?

How much CSF is expected to be collected from each participant at each visit?

What is the aliquot size?

1500 uL (1.5 mL)

1000 uL (1.0 mL)

500 uL (0.5 mL)

Other

How many CSF aliquots will be transferred to Indiana Biobank?

All collected

Other

Please provide details on aliquots to be transferred

How much urine is expected to be collected from each participant at each visit?

What is the aliquot size?

1500 uL (1.5 mL)

1000 uL (1.0 mL)

500 uL (0.5 mL)

Other

How many urine aliquots will be transferred to Indiana Biobank?

All collected

Other

Please provide details on aliquots to be transferred

How many saliva samples (not for DNA) are expected from each participant at each visit?

How many fecal samples are expected from each participant at each visit?

How much blood for PBMCs is expected to be collected from each participant at each visit?

What other sample types do you wish to collect?

Other site/visit details or notes

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Will you need collection kits from Indiana Biobank?

* must provide value

Yes

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Should Indiana Biobank plan for any distributions?

* must provide value

Yes

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What kind of distributions should Indiana Biobank plan for?

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Will Indiana Biobank need to budget for any shipping expenses?

Yes

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What kind of shipping expenses should Indiana Biobank plan for?

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What is the final deadline for receiving the budget?

* must provide value

M-D-Y

Other details/notes

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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.

Indiana Biobank Budget Request Survey

Please fill in the number of participants expected to have a visit in each year:

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