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Required format:

chmgraoUXkwtgnjxYGcwme7G3kMFbNnzkDwm64o2n35ZqviQn6GDANQWTwARmFPHzwpAz

NIA-AD FBS Kit Request System

IMPORTANT: To better track sample shipments, and to harmonize processes across all sites, we are asking all AD-FBS sites to begin using UPS ShipExec™ to send samples to NCRAD.

Starting on Monday, October 30th, kits will no longer contain a preprinted Return Label. Instead, you will generate airbills to return samples to NCRAD using ShipExec™.

If you have any questions or need to set up a ShipExec™ account, please reach out to agericks@iu.edu

Please enter your email address here to receive a confirmation email after completing the survey:

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Today's Date

M-D-Y

3 weeks from now:

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Study Site

* must provide value

Columbia University

Gelanys Castro
622 W 168th Street
PH 19th Floor Room 320
New York, NY 10032
Phone: 212-305-5909
gc2965@cumc.columbia.edu

Emory University

Unknown contact information-Please provide

Indiana University

Kelly Horner

Mayo Clinic Jacksonville

Amber O'Reilly
Mayo Clinic Rochester
Department of Neurology
200 1st Street NW
Rochester, MN 55905
Phone: 507-284-1324
oreilly.amber@mayo.edu

Mayo Clinic Rochester

Amber O'Reilly
Mayo Clinic Rochester
Department of Neurology
200 1st Street NW
Rochester, MN 55905
Phone: 507-284-1324
O'Reilly.amber@mayo.edu

Mount Sinai

Unknown contact information-Please provide

Rush University

Corey Woods
Rush Alzheimer's Disease Center
600 South Paulina Street, Suite 1039
Chicago, IL
Phone: 312-563-4721
Corey_J_Woods@rush.edu

UCLA

Sydney Kilgore
GC: Ariadna Martinez
Mary S. Easton Center for Alzheimer's Disease Research at UCLA
710 Westwood Plaza, Room C-224
Los Angeles, CA 90095-1769
Phone: 310-825-3198
skilgore@mednet.ucla.edu
GC: AriadnaMartinez@mednet.ucla.edu

University of Kentucky

Unknown contact information-Please provide

University of Pittsburgh

Elise Weamer
Unknown contact information-Please provide

University of Texas Southwestern

Luann Tunell
UT Southwestern Medical Center
5323 Harry Hines Blvd, Suite U4.712
Dallas, TX 75390-9129
Phone: 214-645-9018
luann.tunell@utsouthwestern.edu

University of Washington

Sarah Payne
VA Puget Sound Health Care System
S-182-GRECC
1660 S. Columbian Way
Seattle, WA 98108
S-182 GRECC Attn: Sarah Payne
Phone: 206-277-1379
Sarah.payne@va.gov

Washington University, St. Louis

Jennifer Gentsch
WUSM
MSC-8134-66-5120
4444 Forest Park Ave
St. Louis, MO 63108-2212
Phone: 314-747-2981
j.gentsch@wustl.edu

Miami University

Unknown coordinator information-please provide

Wake Forest

Takiyah Starks
Email: tdstarks@wakehealth.edu

Case Western Reserve University

Kristy Miskimen
2109 Adelbert Rd
BRB 701A
Cleveland, OH 44106
Phone: 216-368-5663
klm64@case.edu

*Site uses FedEx to ship samples to NCRAD

Rutgers University

Attn: Mark Gluck
CMBN/Rutgers University-Newark
197 University Ave. (Suite 209)
Newark, NJ 07102

lhchalom@newark.rutgers.edu

PCM Trials

ATTN: Victoria McCammon (COL-01)
9501 Northfield Blvd
Denver, CO 80238

aaap0479@pcmtrials.com
563-505-7984
*Whoever is placing this order, please be sure to use the above email address in the email confirmation box!*

Is the contact name above correct?

* must provide value

Yes

reset

New Contact Name

* must provide value

Is the shipping address above correct?

* must provide value

Yes

reset

New Shipping Address

* must provide value

Expand

Is the e-mail address above correct?

* must provide value

Yes

reset

New E-mail Address

* must provide value

Will your site use FedEx or UPS to return samples to NCRAD?

* must provide value

FedEx

UPS

N/A (ONLY applicable for samples collected at IU Goodman Hall)

reset

Total Number of PBMC/DNA Combo Kits - Ambient (334.3) Requested:

Each kit contains:
2 EDTA (Purple-Top) tubes 10ml - CT001
2 PBMC Sodium Heparin (Green-Top) tubes 10ml - CT008
5 Site and ID labels - LB003
4 Collection Tube Labels - LB003
2 Kit Number Labels - LB003
1 Resealable bag - ST002
1 UPS Laboratory Pak - SH053
1 Biohazard Bag w/ absorbent Tube Sleeves
1 Refrigerant Pack
1 Ambient Shipper
1 UN3373 Category B Label
1 List of Contents Card

Picture of PBMC/DNA kit

Total Number of Plasma/Buffy Coat/PBMC Kits (10680) requested:

Each Kit Contains:

2 EDTA (Purple-Top) Tubes 10ml - CT001
1 15ml Conical Tube - CV004
20 Micronic tubes - 2ml PURPLE cap -CV042
2 Micronic tubes - 2ml GREY cap - CV043
1 Micronic tube - 2ml BLUE cap - CV041
2 Disposable transfer pipette (1ml) - CV002
4 Collection Tube Labels (2 x plasma & 2 x PBMC) - LB003
23 Micronic Tube Labels - LB014
3 Kit Number Labels - LB003
6 Site and ID Labels - LB003
1 Cryobox 48-Slot Rack - CV051
1 Biohazard Bag w/ absorbent sheet - SH015
1 Large resealable bag - ST002
1 small label bag 4"x6" - ST010
2 PMBC Sodium Heparin (Green-Top) Tubes 10ml - CT008
1 Ambient Mailer Kit (SH008):
- 1 Biohazard Bag w/ absorbent sheet
- 1 Refrigerant Pack
- 1 Ambient Shipper w/Insulated Cooler
- 1 List of Contents Card
- 1 UN3373 Category B Sticker
1 Shipping Pouch (SH058)
1 UPS Laboratory Pak (SH053)

ONLY TO BE ORDERED FOR PCM TRIALS

Total Number of Mobile Phlebotomy Plasma/Buffy Coat/PBMC Kits (10536.01) requested:

Each Kit Contains:
Plasma/Buffy Coat Components:
2 EDTA (Purple-Top) Tubes 10ml - CT001
1 15ml Conical Tube - CV004
20 Micronic tubes - 2ml PURPLE cap -CV042
2 Micronic tubes - 2ml GREY cap - CV043
1 Micronic tube - 2ml BLUE cap - CV041
2 Disposable transfer pipette (1ml) - CV002
23 Micronic Tube Labels - LB014
6 Kit Number Labels - LB003
3 Site and ID Labels - LB003
1 Cryobox 48-Slot Rack - CV051
1 Biohazard Bag w/ absorbent sheet - SH015
1 Large resealable bag - ST002
1 small label bag 4"x6" - ST010
1 Processing Schematic
Frozen Shipping Components:
1 X-Small Insulated Frozen Shipper - SH029
1 Dry Ice Label - LB005
1 UN3373 Label - LB008
1 UPS Return Label (provided to RN by PCM management)
PBMC Components:
2 PMBC Sodium Heparin (Green-Top) Tubes 10ml - CT008
3 Site and ID labels - LB003
2 Collection Tube Labels - LB003
6 Kit Number Labels - LB003
1 UPS Return Label (provided to RN by PCM management)
1 FedEx ClinPak/UPS Laboratory Pak (depending on site) - SH053
1 Processing Schematic
Ambient Mailer Components:
1 Biohazard Bag w/ absorbent sheet
1 Refrigerant Pack
1 Ambient Shipper w/Insulated Cooler
1 List of Contents Card
1 UN3373 Category B Sticker

Total Number of Saliva Kits (10712) requested:

Each Kit Contains:
1: Oragene Saliva Collection Kit - CT010
2: Kit number labels - LB003
1: Label for handwritten Site ID, Family ID, and Individual ID - LB003
1: Small Saliva Biohazard Bag with Absorbent sheet - SH013
1: Resealable Bag - ST002
1: Exempt Human Specimen Label - LB007
1: Shipping envelope - ST007
1: Shipping Pouch - SH058

Total Number of Genetic Testing Kits (10666) requested:

Each Kit Contains:
1 - EDTA (Lavender-Top) Blood Collection Tube (3 ml) - CT021
1 - Pre-printed Collection Tube label for whole blood - LB003
1 - Label for handwritten Site ID, Family ID, and Individual ID - LB003
2 - Pre-printed labels with kit number - LB003
1 - Bubble wrap tube sleeve - SH032

Total Number of PBMC Kits - Ambient (185) requested:

Each Kit Contains:
2 PMBC Sodium Heparin (Green-Top) Tubes 10ml - CT008
3 Site and ID labels - LB003
2 Collection Tube Labels - LB003
6 Kit Number Labels - LB003
1 FedEx Airbill/UPS Return Label (depending on site) w/Waybill - SH002
1 Processing Schematic
1 FedEx ClinPak/UPS Laboratory Pak (depending on site) - SH053
Ambient Mailer Kit - SH008:
1 Biohazard Bag w/ absorbent sheet
1 Refrigerant Pack
1 Ambient Shipper w/Insulated Cooler
1 UN3373 Category B Sticker
1 List of Contents Card

Total Number of DNA Kits - Ambient Requested (334.1):

Each Kit Contains:
2 EDTA (Purple-Top) Tubes 10ml - CT001
3 Site and ID labels - LB003
2 Collection Tube Labels - LB003
2 Kit Number Labels - LB003
1 FedEx OR UPS (Depending on site) Return Airbill w/Waybill - SH002
1 FedEx OR UPS (Depending on site) Clinical Pack - SH001
Ambient Mailer Kit - SH008:
1 Refrigerant Pack
1 Ambient Shipper w/Insulated Cooler
1 Biohazard Bag w/ absorbent Tube Sleeves
1 UN3373 Category B Sticker
1 List of Contents Card

Total Number of PBMC Kits - Ambient Requested (185)

Each Kit Contains:
2 PMBC Sodium Heparin (Green-Top) Tubes 10ml - CT008
3 Site and ID labels - LB003
2 Collection Tube Labels - LB003
2 Kit Number Labels - LB003
1 FedEx Airbill (or UPS, depending on site) w/Waybill - SH002
1 FedEx Clinical Pack (or UPS, depending on site) - SH053
Ambient Mailer Kit - SH008:
1 Ambient Shipper w/Insulated Cooler
1 Biohazard Bag w/ absorbent Tube Sleeves
1 Refrigerant Pack
1 UN3373 Category B Sticker
1 List of Contents Card

Total number of Frozen Shipping Supply Kits (10713) requested:

Each Kit Contains:
1 Frozen Shipper (Small frozen shipper/Sm brain box) - SH005
1 Dry Ice Label - LB016
1 UN3373 Label - LB008

Image of frozen shipping kit

Please indicate which visits the kits will be used for:
(Example: You ordered 3 kits; 1 x Visit 1, 2 x Visit 3)

Expand

Do you need extra FedEx/UPS Supplies?
(Please note: FedEx / UPS supplies are included in each kit. Only select "yes" if you need extra supplies)

* must provide value

Yes

reset

Do you need extra UPS Supplies?
(Please note: UPS supplies are included in each kit. Only select "yes" if you need extra supplies)

Extra supplies include: shipping pouch, UPS ClinPak

* must provide value

Yes

reset

Number of extra UPS ClinPaks needed:

Number of extra shipping pouches needed:

Do you need any replacement supplies for expired items?

Yes

reset

What expired supplies do you need replaced?

Expand

"Our standard shipping time for all orders is 3 weeks. If you need any items from this order expedited, please indicate the earliest date you will need these supplies and write which items need expedited in the comment section."

M-D-Y

Our standard shipping time for all orders is 3 weeks.

We can ship this kit request by: ______

If you need any supplies in this order prior to ______, you must contact the NCRAD coordinator for this study: agericks@iu.edu.

IU GOODMAN HALL SITE ACCOMMODATIONS:

Kits should only include blood collection tubes, labels, and bio hazard bag with absorbent sheet

PCM Trials ACCOMMODATIONS:

Kits should NOT include return shipping labels. PCM Trials will use ShipExec.

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