UTSW Alzheimer’s Disease Center (ADC)
Data Request Form
1.
Complete this form and submit to:
Roger N. Rosenberg, M.D., Director - ADC
Department of Neurology and Neurotherapeutics
University of Texas Southwestern Medical Center
5323 Harry Hines Boulevard, MC: 9036
Dallas, TX 75390-9036
2.
The ADC Committee will consider your request. You will be notified regarding the Committee's action.
3.
In an effort to provide optimal support for your projects, please briefly describe the data below that you are requesting from the
ADC database or that you propose to acquire from our subjects. If you are unsure, please indicate that as well, so we can discuss this with
you.
Investigator:
Department:
Date :
Summarize your project
and the data you are
requesting:
Diagnoses of interest:
AD
MCI (what type)
FTD
DLB
Normal Controls
Other





_____
What demographics are
 Age
Gender
Other (specify)
desired?
Imaging
Imaging Data Desired?
 Propose using already acquired data  Proposing using new scans
For new scans, please indicate what sequences you propose. We
________ MPRAGE sense
request that the following sequences from our ADC protocol be
________ ADNI high-resolution T1
acquired and deposited in the ADC neuroimaging database as part of
________ T2 sense
your study. Any omissions will need justification. Our standard 3T
________ T2 FLAIR
MRI protocol consists of the following sequences:
________ DTI (32 directions, 1.75x1.75x2 with 1mm gap) sense
________ fcMRI ________ minutes
Please list any additional sequences (and acquisition times) needed
for your specific study:
Biomarkers
 Data already in database  Frozen samples for new assays
 New sample collections to assay
Blood
 Yes
 No
CSF
 Yes
 No
Neuropsychology
What global measures are wanted (e.g., CERAD total score, MMSE,
______________________________________________________
etc.)?
Specific neuropsychological tests (please see Appendix 1) or cognitive
______________________________________________________
domains?
Are there additional tests that you plan to administer?
______________________________________________________
Need to discuss/consult with a neuropsychologist?
 Yes
 No
Neuropsychiatric and global function variables
Mood (Geriatric Depression Scale)
 Yes
 No Specify: __________________________________
Behavior: (NPI)
 Yes
 No Specify: __________________________________
Function: (CDR, FAQ, TFLS, etc)
 Yes
 No Specify: __________________________________
Clinical variables
Physical exam variables:
_______________________________________________________
UPDRS motor sub-scale:
_______________________________________________________
Clinical history variables:
_______________________________________________________
Other Comments or requests:
Please include any other comments or requests:
Please indicate the tests of interest and desired data:
Please be sure to credit the ADC grant (NIH P30-AG12300) when submitting grant applications and
manuscripts.
Review Status:_________________________________________________________________________
Appendix 1
Neuropsychological Testing Protocols
Neuropsychological data is collected by participant cohort according to the following testing protocols:
Normal Controls / Mild Cognitive Impairment:
-
Mini Mental State Examination (MMSE)
Logical Memory – Story A
Digit Span
Category Fluency
Trail Making Test
Digit Symbol Coding
Boston Naming Test
Visual Reproduction (if MMSE > 23)
California Verbal Learning Test (if MMSE > 23)
Block Design
Letter Fluency (FAS)
Wisconsin Card Sorting Test (if Trails B < 300 sec.)
CERAD
Geriatric Depression Scale
Alzheimer’s Disease / Lewy Body Dementia
-
Mini Mental State Examination (MMSE)
Logical Memory – Story A
Digit Span
Category Fluency
Trail Making Test
Digit Symbol Coding
Boston Naming Test
Visual Reproduction (if MMSE > 23)
California Verbal Learning Test (if MMSE > 23)
Letter Fluency (FAS)
Wisconsin Card Sorting Test (if Trails B < 300 sec.)
AMNART
CERAD
Geriatric Depression Scale