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Required format:

UW BRaIN Lab Resource Request Survey

Thank you for your interest in the UW Biorepository and Integrated Neuropathology (BRaIN) Laboratory, its work and materials!

If you are interested in receiving material for research purposes, please fill out this request form and submit it.

You have the option of returning to an uncompleted survey by pressing "Save and Return Later" at the bottom of the survey. In those situations, you will receive a return code after you have pressed that button. The return code is necessary for you to access the survey at a later time -- please write it down.

When you have fully submitted the request, you will receive a confirmation e-mail sent to the requester's e-mail address, along with a PDF copy of your submission. You will also have the option of downloading a PDF of your submission as well.

Resource Request Survey ID ______

Date request submitted

Requester's First Name

* must provide value

Requester's Last Name

* must provide value

Requester's organization

* must provide value

Requester's Email

* must provide value

Requester's Phone Number

* must provide value

Principal Investigator(s),
Co-Investigator Name(s),
Affiliation(s) and Emails

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Tissue, specimen and data sharing with researchers outside of the University of Washington requires a Material Transfer Agreement (MTA). If you are a researcher outside of the University of Washington, is there currently a MTA in place?

* must provide value

Yes, an MTA is in place

No, please contact me with a draft of your MTA

No MTA needed. I am a University of Washington Researcher and none of this material (tissue or specimens or raw data) will ever be shared outside the University of Washington.

Other issue

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Please elaborate on the nature of your MTA situation

I understand that the tissue and related information will be sent coded and stripped of subject identifiers. The UW BRaIN Lab will maintain a link to the code. However, under no circumstances will the UW BRaIN Lab relinquish the code or any identifying information specific to the specimens to me. I acknowledge that the quality and completeness of data cannot be guaranteed, and that I will use these specimens at my own risk.

* must provide value

Yes

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I agree to acknowledge the studies and associated funding applicable to the tissues in this disbursement, in any publication authored, or presentation made, as a result of the use of the materials. I will work with the UW Biorepository and Integrated Neuropathology (BRaIN) Laboratory to identify the applicable studies and funding. In addition, if this is a collaborative project, any publications that result from using this MATERIAL should identify BRaIN Lab personnel as co-author/s as appropriate according to commonly accepted convention for scientific publications.

* must provide value

Yes

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Principal Investigator's First Name for funding/billing issues

Principal Investigator's Last Name for funding/billing issues

Is your research project funded?

* must provide value

Yes

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If no funding, please elaborate

Funding or Grant Title (if any)

Funding / Grant ID or Number

Source of Funding

Funding Amount

Project Period
This is old data prior to 2023 and does not appear in the resource request survey

Project period start date

M-D-Y

Project period end date

M-D-Y

What resources are you requesting from the Brain Bank or the ADRC Clinical Biospecimen archive?

* must provide value

Post Mortem Brain Bank (Frozen, Fixed, FFPE, post-mortem CSF)

ADRC Clinical Biospecimens (ante-mortem Blood, Plasma, vCSF, Serum, etc.)

Immunohistochemistry Request

Data

Other

Please specify the other resource(s)

Are any of the subjects of your resource request still living?

Yes

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I confirm that I have official IRB approval or exemption to work with banked human tissue

Yes

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If no IRB, specify reason

If you already know the UW Neuropathology identifiers for the donors for your request, please list the IDs here.
If this is for NIH NeuroBioBank donor tissue, please list the specimen IDs here.

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What specific tissue(s) or specimens are you requesting?

* must provide value

Fresh Frozen Tissue

FFPE Slides (Stained or Unstained)

Whole slide images

Whole slide image annotations

Whole slide image analysis

Fixed Tissue

Cell Lines

Serum

Plasma

DNA

Post-Mortem CSF

Ante-Mortem Lumbar CSF

Other

Please specify this other type of specimen

Specimen thickness for FFPE slides

Please describe the resource(s) being requested. Include details on case selection criteria (controls vs cases), details on tissue or specimen(s), region(s) of brain, volumes, special procedures, etc.

* must provide value

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Please specify the data being requested.

* must provide value

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Please provide a brief synopsis of how the resource(s) will be used.

* must provide value

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If you have supplemental information (case lists, images, etc.), please upload it here.
If you have more than one file, please archive / zip the files and upload the archive / zip file here.

Upload file

How would you like to receive the requested resource?

* must provide value

Mail via FedEx

Pick up from Harborview Medical Center in Seattle

Other

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Please specify your other method of receipt

* must provide value

FedEx Billing Account Number

FedEx Shipping Address

* must provide value

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.