Is the PI affiliated with Indiana University?
* must provide value
Yes
No
Is the PI considered an external collaborator, contributor, or affiliated with the IADRC?
* must provide value
Yes
No
What organization or university are you affiliated with? Provide name of organization. If outside of the United States, please provide address.
* must provide value
Is the PI primarily affiliated with:
Academic Institution
Industry
PI Email
* must provide value
If affiliated with IU, please use IU Email address
PI last name:
* must provide value
PI First name:
* must provide value
Please include degree (e.g. MD, PhD)
Title of Project
* must provide value
Name of the project associated with this resource request.
Please provide any Short Study Title/Acronym used
Abbreviated name by which you refer to your study
Are you requesting data (including extracted neuroimaging scan data or sample lists)?
* must provide value
Yes
No
Are you an internal IADRC researcher/requester requesting data ONLY ?
For internal/recurring requests that only need data from Data Core, mark YES here. Otherwise, mark NO to continue with the resource request form. If you need biological samples, neuroimaging scans, OREC data, mark NO.
Yes
No
Types of data being requested:
check all that apply
Requested data fields:
Please list specific data fields if known, or types of data needed if specific data fields are unknown at this point.
* must provide value
Briefly describe the type of data you are requesting
Inclusion criteria:
* must provide value
Exclusion criteria:
* must provide value
Please select a format in which the data will be delivered:
* must provide value
CSV/Excel Spreadsheet SAS Dataset SPSS Stata Summary Report (PDF) Summary Report (Word) Other format (specify below)
Specify other format:
* must provide value
Upload any participant lists, if applicable:
Do you plan to share any data or materials from this request outside of IU?
* must provide value
Yes
No
Do you currently have a Data Transfer Agreement (DTA) in place at IU?
* must provide value
Yes DTA#
No
In progress
Unsure (IADRC will confirm)
Sharing data outside of IU requires a Data Transfer Agreement (DTA).
Date of DTA Approval
* must provide value
Today M-D-Y
DTA ID #
* must provide value
Are you requesting raw neuroimaging scans?
Yes
No
Check all raw neuroimaging scans for this request
Are you requesting EXTRACTED imaging data from neuroimaging scans?
* must provide value
Yes
No
Are you requesting brain tissue?
Yes
No
What type of tissue are you requesting?
* must provide value
How many cases do you need from each group?
Pathological Diagnosis Number of Cases Non-neurodegenerative healthy controls Low AD Intermediate AD High AD Other pathology (ex: LBD, ALS)
Specify regions of interest and minimum amount of tissue (mg/g/number of slides/vials):
Region of interest Amount 1st region of interest 2nd region of interest 3rd region of interest 4th region of interest 5th region of interest
Non-neurodegenerative healthy controls
Other pathology (ex: LBD, ALS)
Justify all regions and amounts requested:
Will the IADRC need to provide dissection or processing
* must provide value
Yes
No
Are you requesting antemortem samples?
Yes
No
(i.e. plasma, not test values obtained from plasma)
Specify the sample type(s), volume of each sample, and cohort distribution:
eg: 0.5ml samples from 10 AD participants, 10 MCI participants, and 10 participants age 66+ with normal cognition
Volume of each sample requested (ml) #Participants with AD #Participants with MCI #Participants age 45 to 65 with normal cognition #Participants age 66+ with normal cognition
Whole blood (limited quantity) Plasma Serum CSF DNA SEE BELOW for additional DNA request details. Form will appear once you fill out columns to the right.
For DNA requests ONLY - leave blank if not requesting DNA:
Quantity per sample (ug):
Number of aliquots per visit timepoint (number):
Require 260/280 purity of 1.65-2.1?
Require 260/230 purity > 1.5?
This may not be evaluated on all samples, only select "YES" if required!
Target concentration (ng/uL)?
Target = 50 allows plated range of 40-100ng/uL. Target = 25 allows plated range of 20-90 ng/uL.
Mimimum concentration allowed (ng/uL):
Absolute minimum concentration for plating = 20ng/uL. If your minimum allowed is higher, note that here.
DNA Buffer:
Additional details regarding sample request
e.g. I would like samples from a specific age range. If requesting more than one sample type, specify if the samples need to come from the same participants.
25 ng/uL 50 ng/uL other
DNA target concentration - other
* must provide value
Minimum DNA concentration allowed
ng/uL
DNA quantity per sample
* must provide value
Number DNA aliquots/visit:
* must provide value
DNA 260/280 required?
* must provide value
Yes No
Yes No
DNA Buffer:
* must provide value
TE PCR H2O
DNA #Participants with AD
DNA #Participants with MCI
DNA #Participant age 45 to 65 with normal cognition
DNA #Participant 66+ with normal cognition
Whole blood (limited quantity)
Whole blood #Participants with AD
Whole blood #Participant with MCI
Whole blood #Participant age 45 to 65 with normal cognition
Whole blood #Participant 66+ with normal cognition
If this request will require a MTA, do you currently have a MTA in place at IU?
* must provide value
Yes MTA #
No
In progress
Unsure (IADRC will confirm)
Sharing tissue or materials outside IU requires a Material Transfer Agreement (MTA).
MTA ID #
* must provide value
Date of MTA Approval
* must provide value
Today M-D-Y
Are you requesting assistance or data from Outreach, Recruitment and Engagement Core (OREC)?
Yes
No
How many participants is your study seeking to recruit from IADRC?
Cohort Details # needed participants with AD particpants with MCI participants age 45 to 65 with healthy cognition participants age 66+ with healthy cognition caregivers Total
cohort healthy control 66+
What is the planned recruitment schedule and will it vary?
e.g. 50 participants per year for 2 years
Are you performing any procedures?
Yes
No
Please, list all procedures and any cognitive tests that would be administered to the participant:
Upload a copy of the informed consent document:
If available. If not, may be skipped.
Are you administering a drug?
Yes
No
Total number of visits a participant will complete?
ex: one visit per year for three years
How long will each visit last?
e.g. 1 - 3 hours
How long will study participation last?
e.g. 2 years
Will participants receive remuneration?
eg: $50 per study visit
Can participants enroll in other studies while enrolled in your study?
Yes
No
Are you requesting staff time to collect additional data or obtain consent etc.?
Yes
No
Are you requesting assistance to recruit participants for your study?
Yes
No
Specify length of time staff will be utilized
Specify hours, months and number of participants (e.g. 2 hours per participant, enrollment period 12 months)
Are you requesting referral data from the CfN Registry?
* must provide value
Yes
No
Project summary
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State the application's broad, long-term objectives.
Specific aims
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State concisely the goals of the proposed research and summarize the expected outcome(s).
Background and significance of research
* must provide value
State concisely the goals of the proposed research and summarize the expected outcome(s).
Approach
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Describe the overall strategy, methodology, and analyses to be used to accomplish the specific aims of the project.
Project funding source
* must provide value
Federal
Non-federal
Unfunded
Agency
Other
Briefly describe other funding source
Approximate start and end date of project
Status of project IRB or Ethics Committee review
Approved
Exempt
In process
Unknown
Please upload a copy of IRB or Ethics Committee review approval document
List all project/performance site location(s)
include: organization name, city and state.
Please list all known co-investigators, significant contributors, and key study personnel.
(i.e. Andrew Saykin, IU, Co-PI)
Plan to submit funding application
* must provide value
Yes
No
Discuss any plans to submit funding application
Discuss any plans to use data obtained from the project to support future funding applications. If no plans, indicate 'not applicable'.
Is this project considered a pilot study?
* must provide value
Yes
No
If this request is not for a pilot study. Include the preliminary data needed to review this request.
If data included in another section, note here.
Will the applicant seek a letter of support?
* must provide value
Yes
No
Cover Letter
* must provide value
Cover letters must be submitted on letterhead with signature. If not, they will be returned for resubmission.
Protocol
* must provide value
Upload PI biosketch
Biosketch should include a personal statement, positions held, selected peer-reviewed publications, and research support.
By what date are resources needed?
* must provide value
Today M-D-Y
Last date possible to fulfill request:
* must provide value
Today M-D-Y
*Our team will make every effort to fill your request by the start date. However, there may be instances where we are unable to completely fulfill a request. If this is the case, will your study accept partial fulfillment of this request?
* must provide value
Yes
No
Point of Contact Name
* must provide value
Who is coordinating this request?
Point of Contact email
* must provide value
Preferred email address for follow-up
Point of Contact Study Role
e.g. study coordinator
Requestor Signature:
* must provide value
Date Signed:
* must provide value
Today M-D-Y
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