Today Y-M-D
Requester First Name:Individual completing survey
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Requester Last Name:Individual completing survey
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Requester Email Address:Individual completing survey
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Best phone number to reach you:
What institution or organization are you affiliated with?
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What department are you associated with?
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Are you the primary point of contact for this request?
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Yes No
Primary Contact First Name:
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Primary Contact Last Name:
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Primary Contact Email Address:
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Are you a student?
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Yes No
Primary Mentor's First Name:
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Primary Mentor's Last Name:
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Primary Mentor's Email Address:
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If you are a student, please provide your primary mentor's name:
Have you previously contacted and/or discussed this request with KU ADRC staff or faculty?
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Yes
No
If yes, please provide the ADRC's staff or faculty member's name:(Include all names if multiple people have been involved)
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Have you previously submitted a KU ADRC resource request related to this project or worked with the KU ADRC on this project?
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Yes
No
Project Short Name:
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i.e., study nickname
Full Project Name:
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Please provide a brief summary of the project and what will be involved.
Include details such as the research question, aims, and/or hypotheses, the basic study methodology or design being used like observation vs. intervention, longitudinal vs. cross-sectional, etc., and planned outcome measures if known.
For projects involving human subjects, include details about duration of study participation, frequency of visits, and planned study procedures like MRI, PET scans, blood draws, lumbar puncture, cognitive testing, etc.
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Upload aims page or protocol if available:
Upload additional project related documents if available:For example, IRB approval, grant application, notice of award, consent forms, recruitment materials, etc.
Planned Project Start Date:(This may be the anticipated or actual start date)
Today Y-M-D
Planned Project End Date:(This may be the anticipated or actual end date)
Today Y-M-D
Is this project funded?
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Funded
Seeking Funding
Unfunded
Are you the Principal Investigator (PI)?
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Yes No
PI First Name:
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PI Last Name:
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PI Email Address:
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PI Institution or Organization:
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PI Department:
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Does the PI have an ORCiD?
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Yes No
Please provide the PI's ORCiD:
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####-####-####-####
Does the PI have an eRA Commons Username?
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Yes No
Please provide PI's eRA Commons Username:
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Are there any additional PI's?
Yes No
Additional PI Email Address
Additional PI Institution
Does the additional PI have an ORCiD?
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Yes No
Please provide the PI's ORCiD?
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####-####-####-####
Does the additional PI have an eRA Commons Username?
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Yes No
Please provide additional PI's eRA Commons Username:
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Are there any additional PI's?
Yes No
Additional PI Email Address
Additional PI Institution
Does the additional PI have an ORCiD?
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Yes No
Please provide the PI's ORCiD?
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####-####-####-####
Does the additional PI have an eRA Commons Username?
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Yes No
Please provide additional PI's eRA Commons Username:
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Are there any additional PI's?
Yes No
Additional PI Email Address
Additional PI Institution
Does the additional PI have an ORCiD?
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Yes No
Please provide the PI's ORCiD?
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####-####-####-####
Does the additional PI have an eRA Commons Username?
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Yes No
Please provide additional PI's eRA Commons Username:
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Are there any additional PI's?
Yes No
Additional PI Email Address
Additional PI Institution
Does the additional PI have an ORCiD?
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Yes No
Please provide the PI's ORCiD?
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####-####-####-####
Does the additional PI have an eRA Commons Username?
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Yes No
Please provide additional PI's eRA Commons Username:
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Please specify what you are requesting from the KU ADRC.
For instance, are you seeking:
A curated dataset from our existing data (i.e., cognitive testing data, actigraphy data, biomarker data) Physical biospecimens (i.e., brain tissue, blood components, CSF) Specific services (i.e., recruiting human subjects, fluid biomarker analysis) Consultation with expert(s) or letter of support Please include all request details (i.e., quantity needed, project timeline). Consultations are available to help you better understand our available resources and services.
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I am requesting:
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check all needed
Please select the content area(s) relevant to your consultation request to explore available resources and/or discuss the feasibility of your study:
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check all needed
check all needed
Neuropathology Core Samples:
check all needed
Maximum sample size requested? What is the maximum number of unique IDs you need samples from to achieve your project goals?
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enter whole number (##)
Minimum sample size requested? What is the minimum number of unique IDs you need samples from to achieve your project goals?
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enter whole number (##)
Please describe the justification for the requested sample size.
For larger studies, this may include a formal power analysis; for smaller studies, this may include an estimate of precision, e.g., confidence interval half-width estimate.
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If multiple specimen types are requested, are all types required per unique ID? For example, if requesting brain tissue, plasma, and serum, select "Yes" if you are only interested in cases with all three specimen types available. Select "No" if you are interested in all available cases regardless of missing specimen types.
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Yes
No
N/A (Only one specimen type requested)
Additional notes if all specimen types are not required for each unique ID:
Requesting longitudinal samples?Are you interested in samples from unique IDs with samples available across multiple timepoints?
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Yes
No
Additional notes for longitudinal samples:
Total # of normal cognition samples:
whole # or leave blank if N/A
Total # of mild cognitive impairment (MCI) due to Alzheimer's Disease (AD) samples:
whole # or leave blank if N/A
Total # of dementia due to Alzheimer's disease (AD) samples:
whole # or leave blank if N/A
Total # of samples from a diagnosis other than normal cognition, MCI-AD, or dementia-AD:
whole # or leave blank if N/A
If samples from other human subjects populations are needed, please describe:
How much buffy coat is needed per sample? (Stored at -80° in 0.5ml cryovials)
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How much CSF is needed per sample? (Stored at -80° in 1ml cryovials)
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How much plasma is needed per sample? (Stored at -80° in 0.5ml cryovials)
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How much platelet free plasma is needed per sample? (Stored at -80° in 1ml cryovials)
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What volume of platelets is needed per sample? (Stored at -80° in 1ml cryovials)
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How much serum is needed per sample? (Stored at -80° in 0.5ml cryovials)
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How much whole blood is needed per sample? (Stored at -80° in 0.5ml cryovials)
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Please provide any additional relevant specimen details or notes:
Neuroimaging requested:
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check all needed
Biomarker Core Service(s) Requested:
check all needed
Outreach Recruitment and Engagement Service(s) Requested:
check all needed
Please mark this field if there is not a specified enrollment goal for this project.
Otherwise, please complete the following fields to enter the enrollment targets.
No Specified Enrollment Goal
What is the total enrollment goal (n)?
LEAVE BLANK if N/A
Number of participants with non-impairment (i.e., normal cognition) needed:
LEAVE BLANK if N/A
Number of participants with MCI due to Alzheimer's disease needed:Mild Cognitive Impairment
LEAVE BLANK if N/A
Number of participants with dementia due to Alzheimer's disease needed:
LEAVE BLANK if N/A
Number of participants with Down Syndrome needed:
LEAVE BLANK if N/A
Number of participants from other population needed:(other than cognitively normal, MCI-AD, dementia-AD, or Down Syndrome)
LEAVE BLANK if N/A
If other human subject population needed, please describe:
Please provide any relevant details on human subjects recruitment goals, population, clarifications, or instructions:
Do participants receive compensation?
Yes
No
If yes, describe compensation received.(form of compensation, amount, stipulations for receiving compensation, etc.)
Are any study results disclosed to participants?
Yes
No
If yes, describe results disclosed. (type of information shared, frequency of disclosure, format results recieved, etc.)
Clinical Research Operations Service(s) Requested:
check all needed
Data Management and Statistical Core Service(s) Requested:
check all needed
Neuroimaging Core Service(s) Requested:
check all needed
Please describe the other imaging requested:
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Please add any additional relevant neuroimaging details or notes:
Other Service(s) requested:
Fluid Biomarker Analysis (Biospecimens)
Respiration and glycolysis flux analysis in cells or isolated mitochondria (Biospecimens)
Mitochondrial DNA haplotyping, single nuclear variants, heteroplasmy, copy number; Mitochondrial RNA, DNA, enzyme activity, and protein analyses (Biospecimens)
Next generation DNA sequencing, genotyping (Biospecimens)
Bioenergetics, mitochondria isolation, and oxidative stress related assays (Biospecimens)
Genomic and proteomic applications (Biospecimens)
Preparation of cybrid cell lines (Biospecimens)
Recruitment and Marketing Planning (Human Subjects)
Planning for the recruitment of populations under-represented in research or at a higher risk
Study Specific Screening (Human Subjects)
Study design and sample size estimation (Existing Datasets)
Database development and support (Existing Datasets)
Data analysis support (statistical analysis, study oversight, graphics/data visualization) (Existing Datasets)
Study interpretation and manuscript development (Existing Datasets)
Statistical and 'omics methods development (Existing Datasets)
Study Coordination Staff Support (Clinical Research Coordinator/Research Assistant) (Human Subjects)
Clinician Rater Staff Support (Human Subjects)
Psychometrist Staff Support (Human Subjects)
Regulatory Staff Support (Human Subjects)
Other Service(s) Requested
Please describe the other service(s) needed:
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Please provide any additional notes, clarifications, or instructions for the service(s) requested:
Neuroimaging or Neurovascular Data and/or Images:
Please describe the data or records needed:
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Please select whether cross-sectional or longitudinal data is need: (Cross-sectional meaning data from only 1 visit ; longitudinal meaning data from multiple visits)
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Cross-sectional data
Longitudinal data
Will you be sharing or sending these materials/data to anyone outside of your immediate research team/lab/office?Due to Center policies, the approval of this request only covers the use of materials/data by your laboratory/office/staff . If the material/data is to be shared or analyzed outside your laboratory, please inform us now. You may request permission to share this material in the future by contacting the ADRC.
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Yes
No
If yes, please identify who will receive our research materials and describe the reason sharing is needed.
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Please open and review the KU ADRC's Resource Request & Sharing Policy attached below. After, please complete the acknowledgement of review.
I have read the KU ADRC's Resource Request & Sharing Policy. I understand that if my project is approved, I will be required to complete progress and final reports at the request of the ADRC. Failure to complete these reports in a timely manner may result in the termination of the project.
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Agree
Disagree
Date of Full Request Survey:
Today Y-M-D
Complete funding information on the Finances Budget form. Date Request Last Updated:(Internal Use Only)
Today Y-M-D
Updated Request Notes: (Internal Use Only)
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