The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

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The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

RESOURCE UTILIZATION REQUEST/AGREEMENT FORM

Returning?

A A A

Please complete the form below to initiate your resource request. A written study protocol (indicating the specific aims, background/significance, methods/procedure and analyses of results) must accompany this request. The specific resources requested (e.g., subject lists, data variables, nature and number of subjects, tissue sample details, etc.) must be precisely specified either in the protocol or in a cover letter.

Date of Request

M-D-Y

Name:

* must provide value

Institution

* must provide value

Phone:

* must provide value

Are you also the point of contact?

* must provide value

Yes

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Name of the Contact Person

Contact Person's Phone number

Contact Person's Email Address

Project Title or Name of Protocol

* must provide value

IRB Approval#

IRB Approval Date

M-D-Y

Principal Investigator

* must provide value

Co-Investigator(s)

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Study protocol and other documents

Upload file

Type of Request?

* must provide value

a. Data

b. Bio-specimen (Brain Tissue, Blood, CSF)

c. Subjects/ Participants

d. Statistical Consult

e. Both, a and b

f. Both, a and c

g. Both, b and c

h. a, b and c

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Did you explore our inventory of available data and biospecimen to understand the availability of data and determine how the available resources match the requirements of your project? You can access the Tableau system by clicking here.

Resources being requested for study protocol (check all that apply)

Biochemical/genetic

Caregiver

Clinical/Observational

Demographic

Laboratory

Neuroimaging

Neurological

Neuropathological

Neuropsychological

Psychosocial Data

Other

Please specify "other resources" being requested

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Please identify the demographic forms you would need the information from

NACC Form A1: Subject Demographics

NACC Form A2: Co-Participant Demographics

NACC Form A3: Subject Family History

Hollingshead Index of Social Position (PARTICIPANT)

Please identify the caregiver forms you would need the information from

Caregiver Core Interview Notes

Please identify the Clinical/ Observation forms that you need the information from

NACC Form A4: Subject Medications

Current Medications: Presecription and Over-the-Counter

NACC Form A5: Subject Health History

NYU Additional Medical History

Charlson Comorbidity Index

Informant Interview: Clinical History

Epsworth Sleepiness Scale

Mayo Fluctuations Questionnaire

Sleep Questionnaire

NACC Form B7: Functional Assessment - Functional Activities Questionnaire (FAQ1)

NACC Form B5: Behavioral Assessment - Neuropsychiatric Inventory Questionnaire(NPI-Q1)

MEMORY Information - Informant

LANGUAGE-Informant

ORIENTATION

JUDGEMENT AND PROBLEM-SOLVING

COMMUNITY AFFAIRS - Informant

HOME AND HOBBIES - Informant

PERSONAL CARE- Informant

Participant Interview: Clinical History (Obtained from Participant)

ADCS: Cognitive Change Index

NACC Form B6: Behavioral Assessment - Geriatric Depression Scale (GDS1)

Montreal Cognitive Assessment (MoCA)

Participant Interview: Past Memory, Orientation, Language, Attention, Praxis and Concentration

NACC Form B1: Evaluation Form - Physical

NYU Physical Examination Obtained from Participant

Mini-Physical Performance Test (Mini-PPT)

Neurological Examination Obtained from Participant

NACC Form B8: Evaluation -Neurological Examination Findings

NACC Form B4: Global Staging - Clinical Dementia Rating (CDR): Standard and Supplemental Brief Cognitive Rating Scale (BCRS)

Global Deterioration Scale (GDS)

NACC Form B9: Clinician Judgment of Symptoms

NACC Form D1: Clinician Diagnosis

NACC Form D2: Clinician - Assessed Medical Conditions

Please identify the neuropsychometric data forms that you would need the information from

NACC Form C2: Neuropsychological Battery Scores

Craft Story 21 Recall Immediate

Benson Complex Figure Copy Immediate

Number span test : Forward

Number span test : Backward

Category Fluency

Trail Making Test

Craft Story 21 Recall Delayed

Benson Complex Figure Copy Delayed

MINT (Multilingual Naming Test)

Verbal Fluency: Phonemic Test

Auditory Verbal Learning Test - Immediate Version A

Auditory Verbal Learning Test - 30 minute Delay

Perceptual Speed

MMSE

WAIS - R (DSST)

Guild Memory Test - Form A

Guild Memory Test - Form B

Psychometric Screening Data Summary Sheet

Please identify the neuropsychometric data forms that you would need the information from

NYU-ADC Psychosocial Assessment

Please identify the neuropathology data forms that you would need the information from (Current NACC version 10)

NACC Neuropathology (NP v. 10) form

NACC Neuropathology (NPv. 11) form

Regions for which volumetric measures are sought?

Subcortical Region

Left Cortical Region

Right Cortical Region

Do you require a copy of the scans as well?

Yes

NYU ADRC Data Management and Statistical Core (DMS) also offers statistical consultations. Do you want a DMS team member to call you for statistical consult?

Yes

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Participants/ Subjects

Yes

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Please describe your criteria for the subjects

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Biospecimen

Brain Tissue

Blood

CSF

Select type of biospecimen requested

Fresh Tissue

Frozen Tissue

Tissue from Paraffin Archive

Tissue from Formalin Archive

Region Desired
(for brain tissue only)

Quantity/ Amount Desired (Blood)

Quantity/ Amount Desired (CSF)

Matched Normals Needed

Yes

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Responsible Billing Party

* must provide value

Requester

Principal Investigator

Other

Please specify the billing party

How did you hear about us?

* must provide value

Event

Co-worker/ Colleague

Internet Article

Internet Search

Newspaper Article

Other

Social Media (Facebook, Twitter, Instagram)

Website - NYU

Website - NYU Alzheimer's Disease Center

Website - NYU Center for Cognitive Neurology

Website - Other

Please specify the website where you heard about this dataset:

Please specify where you heard about this dataset:

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