DIAN Observational Biospecimen Request Form

Please read the terms and obligations of using DIAN data. By submitting this request, you are acknowledging your acceptance of and willingness to comply with the terms stated.

DIAN Obs Biospecimen Requests

Investigator Information

Enter the investigator’s first name.
Enter the investigator’s last name.
Enter the investigator’s institution.
Enter the investigator’s email address.
Enter the investigator’s phone number.
Are you a member of the DIAN Steering Committee?
Please provide up to 4 concise aims below 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.

Source of Support

Please do not list here the DIAN grant or the DIAN PI (Bateman); please provide information specific to this request.
Please do not list here the DIAN grant or the DIAN PI (Bateman); please provide information specific to this request.
If you are a student, graduate student or fellow, please provide the name of your faculty mentor on this project.

Purpose Information

What is the purpose of this request? Check all that apply.

Purpose
Is it okay to include your data in the DIAN Central Neuroimaging Data Archive?
If you selected “No” to this question, provide your reasons in your submitted Research Rationale (see below).

Diagnostic Categories Requested

Submit up to 5 individual requests per form submission below:
Please be aware that sample sizes may be subject to availability of ADRC materials, resources, and staff.

Key: DAT = Dementia of the Alzheimer Type

(based on autopsy)
(based on autopsy)
 

(based on autopsy)

 

 

(based on autopsy)
(based on autopsy)

Type of Tissue Requested

Please specify the following information about your requests above:

(for brain tissue only)
DNA should be noted in µg.
CSF/Plasma/Serum in µl.
(for brain tissue only)
DNA should be noted in µg.
CSF/Plasma/Serum in µl.
Sample size determined by:
Specify other details regarding diagnoses and any inclusion/exclusion criteria (e.g. age, race, gender, comorbidities, etc.).

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.
Research Rationale:
Please send your research rationale as an attachment to zangela@wustl.edu. Your rationale should include the following information and not exceed 2 pages (references and figures excluded): purpose, background and preliminary data, methods, inclusion and exclusion criteria, analytic plan, and sample size justification.

Biosketch:
Please also send an NIH Biosketch or brief curriculum vitae to zangela@wustl.edu.

Code Access Agreement:
All investigators accessing or receiving DIAN data or tissue must return a signed code access agreement prior to receipt of data/tissue. Please fill out this form and return it to zangela@wustl.edu.

Maximum file size: 16MB

If don’t want to email your files and have them ready, you can upload your Research Rationale, Biosketch and Code Access Agreement files by attaching them to this form. The maximum size limit for all files combined is 16MB.