Form 1 Access Request

K?ltlin Taylor

NeuroBioBank

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Submit a Request for Tissue Samples
Plannin,; th• RM1UHt

[ Complottingth• Form
_

[ Tiuu• Nuds

Planning Your Tissue Request
• The ,nur� 1eol1idive yuu, suli'.ed d,ar<1deiistics, the'"'-"' likely" L>roh1 l,;,mk will iid'J<:'

• If yvu '" e 11vl S\Jft, pred�ly wltill tissue, lis,ue ,egion�, v, quorrlili,:,:; <1re bet Iv, yuur

tissue that meets your requirements. Ensure that any restrlcLions you p[�a, on s•Jbject

research project, please submila request forhelpw lhe NIH NeuroBnal IMtitute� of Health' (NIH Extramural Grant, Cooperati1JeAtreement, Contracl 1>rNIH lnlramural

Rnean:h) •

0

1,0

Fumlin;: Institution Type•

rState Grwcrnmcnt

Fundinli'. Or.;anization

Award Number

Name of funding Agency '

■

Specimen Shipping Information

" U,;e oa1ne address ao lioted above

Pluse wmplete ONE of the follow in;: fields:•

Country ...

C..nierAccount Humber

11.ddress 1 •

1 Wee will send shi�mfnt label

Addre•• 2

Lab Contact Email

City•

Prefrm-ed ShippingCarrier•
Zip/Postal Code'

State/Province/Re;:ion •

Shipping Notes

II Requested Specimens
Specimen �placements

TheNl'l.lrU \JioL><111k lllUI o;igi11<1I reque�l. fo help in �l�di11g �PJ'l-'P'i"'le r�l'ecimen(s)

II Request Details
TitlP of R""'"arch Plan•

This neld "'ill ,p..,ar at the lop of your MTA.
Describe this request, Including a summary of the ratlt1nale, main hypothesis and proposed research alms•

h bnef ,wervoew of your research needs.

Type of assay{s){ platform(•) to be used•

Describe the assa� k1t(s)iplatform1s) to be used, if appl,rnble.

Hav@ you u1ed the propoud methods with human pott-mon@m tinne� �
Yes

11 thl1 a pilot study�•
, Yes
No

Rationale for biospecimens requested•

Please prnvrde a detailed ex,ilananon for your specimencelect1on {seenan4, above). Th!S will help
p rocess your reqt1est more cuickly and ensure the selection c,/ appropriate specimens.

WIii th,e resulls be used for• commerdal purpose? '
'Yes
No

Commenls

Neuro6ioBank Data Sharing
Rf!SedJd!t!rs cu,1Jrchcrs arc strongI� encouraged to su�mrt gc,nnmi� □nd1. or tr□nscMprnm:c dm□ gcm:,r□!ed fram �J (:,IJmBioBJnk spc�imcns m the NcuroBioElank
Uata Rc-po$�ory inNl�11l DetaArchive.
Pluse attach a CV for lhe .Orjncipal 1nvesti;ator. •
When you attach �-,.,tile, �lease make sure the Document Type 1s set to "Pnnc,pal lnveshgator S\'"

We also encour�ge uploading any additional supportng documenla'.i on 1h31 is rn'.evant to your tissue re(luest. Upload:ng suppmtITTg dornmenlation for your rntionale, power anal11sis,
e.c may impmve re�ueSI re1Jiew ILmes '

Attach Files
File

lleu r0Bi0B<>11k Image R�posiwr; lnotn.oct ion,.pdf

Attac

PMncipal lnvestigatcr CV
Power Analy5is
Rationale Sup�of":ing Documenl3li(m
Images

-

Size

1.2 MB

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