Tissue Request Form | Knight Alzheimer Disease Research Center

Tissue Request Form

Before you begin...

Have you reviewed the Guidelines & Data Available page?
Have you considered searching existing requests to avoid duplication of effort or conflicting research projects?
Do you have your research rationale ready? The Word or PDF file (3 page limit not including references and figures) should include the following information: purpose, background and preliminary data, methods, inclusion and exclusion criteria, analytic plan, sample size justification and a list of data variables.
Resource request forms must be completed in one sitting. You cannot submit a partial request and update it later.

Note: This form, and your research rationale submission, should not be considered a "shopping cart" for needed data. Communication with the data core staff will help refine your request based upon your needs and the availability of Knight ADRC materials, resources, and staff.

Investigator Information

Name:

First

Last

Institution:

Department:

Email:

Phone:

Phone Extension:

Research Project Information

Project Title:

Please provide up to 4 concise aims below for your project. At least one aim must be submitted.

Aim 1:

300 character limit

Aim 2:

300 character limit

Aim 3:

300 character limit

Aim 4:

300 character limit

Source of Support

Provide the source of support for the project for which you are requesting this data.

Type of Funding:

Sponsor:

Grant Number:

Enter N/A if not applicable.

Start Date:

End Date:

Total Amount for Entire Period:

Digits only. If amount is indeterminate, e.g. Internal Funding, enter 0. This information is reported to NIH. Please be sure it is accurate.

Primary Investigator:

Are you a student, graduate student or fellow?

Yes

Faculty Mentor's Name: