Biospecimen Requisition Form

Research project Title *

200 characters

Check here

if any of the investigators listed on the application are South Texas Alzheimer’s Center (STAC) employees if any of the investigators listed on the application are Glenn Biggs Institute employees if any of the investigators listed on the applicated are UT Health San Antonio employees

Lead Investigator*

First Name

Last Name

Email*

Phone*

Position*

Institution

Contact Investigator

Same as lead investigator

Alternative contact

First Name

Last Name

Email

Phone

The purpose of this application is to determine whether the proposed project is feasible and within the goals of the South Texas Alzheimer’s Center/Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases. To fulfill this, we ask applicants to provide a short overview of their research question, aims, and analysis plan. To avoid delays in accessing information or samples, be sure to obtain permission from your institutional IRB before submitting this form.

What type of dataset will your project require? Please note that we reserve the right to contact your IRB and confirm any approvals/documents we receive.

A data set with limited identifiers and/or biological samples. For example, dates, city of birth, complete zip code, etc.

Please visit John Hopkins for more information about identifiers.

Prior to data and/or sample disbursement, we must receive an exempt review from the IRB, as well as a Waiver of HIPPA authorization.

A data set with identifiers and/or biological samples. For example, names, contract information, identifiable numbers (e.g. MRN, SSN), biometric identifiers, etc.

Please visit John Hopkins for more information about identifiers.

Prior to data and/or sample disbursement, we must receive evidence of an expedited or full board IRB approval with a HIPPA waiver and possibly a waiver of informed consent.

Have you obtained IRB approval for your research plan?*

Yes No

Document upload*

No File Chosen

File uploads may not work on some mobile devices.

if yes

Have you obtained a data use agreement (DUA) or material transfer agreement (MTA) for this project? Note: If you are a researcher outside of STAC, a DUA and/or MTA initiated by your institution is required prior to receipt of samples and/or information. *

Yes No

Document upload*

No File Chosen

File uploads may not work on some mobile devices.

if yes

A DUA and/or MTA will be provided at a later date
Anticipated date of MTA/DUA

Analysis plan. Be sure to include background information, your research objective, and your methodology, including justification for the volume of each biospecimen you are requesting.

700 word max

Place a check mark next to each biospecimen that you are requesting.

EDTA plasma

Number of samples

Volume per sample (ul)

Serum

Number of samples

Volume per sample (ul)

DNA

Number of samples

Volume per sample (ul)

RNA

Number of samples

Volume per sample (ul)

PBMC

Number of samples

Volume per sample (ul)

When do you expect to complete this project? Note, we require all users to cite the Glenn Biggs Institute as the source of the data, as well as our funding sources, such as STAC. We will send quarterly reminders to all listed study staff.

Month/Year

Are you generating new data

Yes No Unsure

I agree to share with the Glenn Biggs Institute if requested?

Anticipated project completion date