Date of Request
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Today D-M-Y
Principal Investigator Information: * all fields required
PI First Name PI Last Name PI Email PI Telephone
PI First Name
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PI Last Name
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PI Email
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What is your primary telephone number?
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Primary Affiliation:
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OHSU
Other
Please fill in the inforation about the PI's primary academic affiliation: * all fields required
Institution name Institution street address Institution city Institution state Institution zip-code
Please indicate the PI's primary academic affiliation:
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Please enter the PI's primary academic affiliation's street address:
Please enter the PI's primary academic affiliation's city:
Please enter the PI's primary academic affiliation's state:
use state abbreviations (i.e. OR, WA, CA)
Please enter the PI's primary academic affiliation's zip code
Are you the primary study contact for the requesting project?
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Yes
No
Yes
No
Study primary contact information (other than PI): * all fields required
Primary contact first name Primary contact last name Primary contact email Primary contact phone number
Primary contact's first name?
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Primary contact's last name?
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Primary contact's email?
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Primary contact's phone number?
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Project Title
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Describe your project and its aims:
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Is this a funded project?
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Yes (specify funder(s))
No
Please list the funding institutions associated with this project:
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The following section will ask you about the types of data you are interested in receiving.
Here are data dictionaries associated with the data streams in our center:
When do you need the data from this request?
Now D-M-Y H:M
What is your intended use for this data?
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Abstract
Dissertation/Student Project
Grant: Currently Awarded
Grant: Potential Submission
Poster
Publication
Research: Exploratory
Support Center Operations
Select the variable groups your are requesting (please review the above data dictionaries for more details about the variables listed). Select all that apply.
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Audio/Video Recording Data
Bio-specimen Data
Brain Pathology
Digital Biomarker Sensor Data
Imaging Data
NACC UDS Clinical Data
Non-NACC Clinical Data (demographic data, online weekly health data, online reported data, sleeping, loneliness, social isolation, physical activities, comorbidities measures, other cognition measurements)
Neuropsychological Testing Data
Online Health Update Forms
Online Survey Data (Not Health Update Form)
Transcribed Speech Data
What bio-specimen data do you need? (check all that apply)
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CSF
DNA
Plasma
Saliva
Serum
Urine
You have indicated you would like CSF: How much would you like (half ml increments)
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You have indicated you would like DNA: How much would you like (half ml increments)
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You have indicated you would like Plasma: How much would you like (half ml increments)
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You have indicated you would like Serum: How much would you like (half ml increments)
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You have indicated you would like Urine: How much would you like (half ml increments)
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What are you sample parameters?
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Please describe the clinical and/or demographic data you need for your sample pull? If none, please mark "NA".
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You indicated you were interested in Digital Biomarker Sensor Data. Please indicate the metrics you are inerested in receiving:
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Computer use (not app specific information)
Driving data (requires additional follow up with research team)
Emfit/BedMat Data
Mouse Data
NYCE Home Sensor Data
Pillbox Usage
Scale Data
Watch: Process (aggregate daily steps and sleep metrics)
Watch: Raw
Other (specify)
Please list additional digital biomarker sensor metrics you are interested in.
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DICOM Data
Volumetric Data
Other (specify)
Please specify any imaging data you need not listed:
If you know the name of the study you wish your data to come from, please enter it here:
Please use the data dictionaries provided above to upload a '.csv' or '.doc' of specific variables you are interested in receiving in your data set.
Please list any existing fully available data sets you would be interested (a list can be found on our website here )
What is your preferred method of file type?
CSV
Excel Spreadsheet
Other
What additional file type would you prefer:
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Do you need the whole cohort or a subset?
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Whole Cohort
Subset
Unkown
You indicated you needed a subset of the cohort requested. Please provide more details regarding your subset, including any known identifiers (subject IDs, OADC numbers, home IDs, etc)
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What timepoints do you need?
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Baseline only
All timepoints
Other/Specific timepoints
You indicated that you require additional timepoints not listed. Please enter details about those timepoints:
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Does this request require a statistical consult?
Yes
No
The availability of statistical consult will be review by request.
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