DIAN-TU Data and/or Biospecimen Request Form | Dominantly Inherited Alzheimer Network

Investigator Information

Date of Request

First Name

Enter the investigator’s first name.

Last Name

Enter the investigator’s last name.

Institution

Enter the investigator’s institution.

Email Address

Enter the investigator’s email address.

Phone Number

Enter the investigator’s phone number.

Project Title

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.

Project Aim 1

Project Aim 2

Project Aim 3

Project Aim 4

Source of Support

Type of Funding

Sponsor

Grant Title

Please do not list here the DIAN grant or the DIAN PI (Bateman); please provide information specific to this request.

Grant Number

Please do not list here the DIAN grant or the DIAN PI (Bateman); please provide information specific to this request.

Principal Investigator

Faculty Mentor

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

Do you have IRB or Ethics approval?

IRB/Ethics Approval Number

IRB/Ethics Approval Date

Date Resources Needed

Date of Estimated Completion

Request Specifics

Would you like baseline data only or the full dataset?

Baseline data only

Baseline and post-randomization data

What type of data are you requesting?

Processed data

Raw imaging files

Tissue or biofluid

You may select more than one option.

From what cores do you need data?

Clinical Core (demographics, CDR, MMSE, etc.)

Cognition Core (paper and pencil tests, computerized measures, etc.)

Imaging Core (PET, MRI, etc.)

Biomarker Core (CSF etc.)

Genetics Core (APOE, Mutation information etc.)

Neuropathology Core (Neuropathologic assessment and diagnosis)

You may select more than one option.

HIPAA Section

Will you be sharing/sending these materials/data to anyone outside of your immediate research team/lab/office?

Yes

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 assemble the following documents and e-mail to dian-tudatarequest@wustl.edu or upload in the File Upload box below:

Research Rationale (2 pages max) that includes:
- Specific aims and hypotheses
  - Description of pilot data for tissue requests
- Analysis Plan
- List of variables requested
- Plan for the protection of the data (e.g., secure cloud storage etc.)
IRB or Ethics committee approval (Note: Request can be submitted if IRB review is still pending, however no data will be released until approval is obtained)
NIH style biosketch or short CV

File Upload

Maximum file size: 32MB

If don’t want to email your files and have them ready, you can upload your Research Rationale, IRB or Ethics Committee approval and NIH style biosketch or short CV files by attaching them to this form. The maximum size limit for all files combined is 32MB. File formats that are acceptable are: pdf, rtf, doc and docx. No more than 4 files may be uploaded.