Today M-D-Y
First Name:
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Last Name:
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Institution or organization you are associated with:
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Department you are associated with:
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Best phone number to reach you:
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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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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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In simple terms, what are you looking to request from the KU ADRC?
For example, a curated dataset from existing KU ADRC data, physical biospecimens like brain tissue or different blood components, or specific KU ADRC services like assistance recruiting human subjects. Please include everything you are looking to request even if you are unsure of the available options as consultation will be provided to better understand our offerings.
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Upload aims page or protocol if available:
Upload additional project related documents if available:E.g. grant application, notice of award, consent forms, recruitment materials, etc.
Planned Project Start Date:(This may be the anticipated or actual start date)
Today M-D-Y
Planned Project End Date:(This may be the anticipated or actual end date)
Today M-D-Y
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 "Guidelines and Policies for Requesting KU Alzheimer's Disease Research Center Resources", attached below. After, please complete the acknowledgement of review.
I have read the Guidelines & Policies for Investigators Requesting KU ADRC Resources. 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 M-D-Y
I am requesting:Requests for biospecimens and neuroimages will come with a minimal de-identified demographic dataset. Request "Existing Datasets" only for more extensive data.
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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
Biospecimens Requested:
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check all needed
Total sample size requested? I.e., how many unique IDs do you need samples from?
enter whole number (##)
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.
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?
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) samples:
whole # or leave blank if N/A
Total # of Alzheimer's disease (AD) samples:
whole # or leave blank if N/A
Total # of samples from a diagnosis other than normal cognition, MCI, or AD:
whole # or leave blank if N/A
If samples from other human subjects population need, please describe:
How much buffy coat is needed per sample? (Stored at -80° in 0.5ml cryovials)
How much CSF is needed per sample? (Stored at -80° in 1ml cryovials)
How much plasma is needed per sample? (Stored at -80° in 0.5ml cryovials)
How much platelet free plasma is needed per sample? (Stored at -80° in 1ml cryovials)
What volume of platelets is needed per sample? (Stored at -80° in 1ml cryovials)
How much serum is needed per sample? (Stored at -80° in 0.5ml cryovials)
How much whole blood is needed per sample? (Stored at -80° in 0.5ml cryovials)
Please provide additional specimen details and/or notes as applicable:
Neuroimaging requested:
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check all needed
Please describe the other neuroimaging needed:
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Please provide additional neuroimaging details and/or notes as applicable:
Service(s) requested:
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Fluid Biomarkers Analysis
Respiration and glycolysis flux analysis in cells or isolated mitochondria
Mitochondrial DNA haplotyping, single nuclear variants, heteroplasmy, copy number; Mitochondrial RNA, DNA, enzyme activity, and protein analyses
Next generation DNA sequencing, genotyping
Bioenergetics, mitochondria isolation, and oxidative stress related assays
Genomic and proteomic applications
Preparation of cybrid cell lines
Recruitment and Marketing Planning
Study Specific Screening
Study design and sample size estimation
Database development and support
Data analysis support (statistical analysis, study oversight, graphics/data visualization)
Study interpretation and manuscript development
Statistical and 'omics methods development
Study Coordination Staff Support (Clinical Research Coordinator/Research Assistant)
Clinician Rater Staff Support
Psychometrist Staff Support
Regulatory Staff Support
Other Service/s Requested
check all needed
Please describe the other service/s needed:
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Please provide additional notes, clarifications, or instructions for the service/s requested as applicable:
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
What is the total enrollment goal (n)?
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Number of participants with non-impairment needed:
whole # or leave blank if N/A
Number of participants with MCI needed:(mild cognitive impairment)
whole # or leave blank if N/A
Number of participants with Alzheimer's disease needed:
whole # or leave blank if N/A
Number of participants with Down Syndrome needed:
whole # or leave blank if N/A
Number of participants from other population needed:(other than cognitively normal, MCI, AD, or Down Syndrome)
whole # or leave blank if N/A
If other human subject population needed, please describe:
Please provide additional notes on recruitment, clarifications, or instructions as applicable:
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.)
Is the proposed study funded?
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Funded
Unfunded / Seeking Funding
Complete funding information on the Finances Budget form. From what source are you seeking funding (NIH, RFA, Company, Foundation, etc..) Please be as specific as possible.
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What was/is the funding application due date?
Today M-D-Y
Date Request Last Updated:(Internal Use Only)
Today M-D-Y
Updated Request Notes: (Internal Use Only)
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