NEALS Application for Membership
Please remember to include a Letter of Intent AND Your CV with your submission
Name: ________________________________________________________________________
Affiliation: _____________________________________________________________________
Position: ______________________________________________________________________
Contact Information
Phone: _________________________________________________________________
Fax: ____________________________________________________________________
Mailing Address: _________________________________________________________
City: ____________________________
State: _____________________
Zip Code: ________________________
Email: ___________________________________________
Site URL (if applicable): ___________________________________________________________
Please return all application materials to:
NEAL S Coordination Center
ATTN: NEALS Program Manager
50 Staniford Street, Floor 4, Room 401I
Boston, MA 02114
Ph: 617-724-7398
Fax: 617-724-4005
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ALS Trial Resources Survey
Please answer all that apply to your site’s facilities. Your answers will help us maintain a comprehensive
inventory of our sites’ resources and capabilities
Outcome Measures
Yes
No
Quantitative Muscle Testing Equipment
Hand-Held Dynamometer
Motor Unit Estimation (MUNE)
Spirometer *
*If yes, please note make and model number ________________________________________________
Research Imaging Access
Yes
No
Magnetic Resonance Imaging (MRI)
Spectroscopy
Position Emissions Topography
Chest X-Ray
Ultrasound
Auxiliary Research Modalities
Please list any other research modalities at your site: __________________________________________
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Other Resources and Equipment
Other Resources and Equipment
Yes
No
Refrigerator
-20 degree freezer
-80 degree freezer
General Clinical Research Center (GCRC)
EKG Machine
Dry Ice
Centrifuge
Regular
High Speed (RPM_____)
N/A
ALS Trial Experience
Please list each ALS trial your side has been associated with
ALS Trial Name
Enrollment Start
and End Date
Target Enrollment
Number
No. of Subjects
Enrolled
No. of Subjects
Completed
ALS Patient Base
How many ALS patients total does your site follow per year?
_________________
How many new ALS patients has your site seen in the last 12 months? ____________
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ALS Trial Personnel
Please list all personnel at your site who participate in ALS research. Should your site be selected for
NEALS membership, all personnel listed will be considered NEALS members. Please indicate if the
member is a co- or sub- investigator; Research/Study Coordinator; Clinical Evaluator, Research Nurse;
Basic Scientist; or Other (personnel may have more than one role).
First Name
Last Name
Degree(s)
Role at Site
Phone No.
Email Address
BEFORE YOU SUBMIT:
Application for NEALS Membership Checklist
Letter of Intent
Completed NEALS Application
CV
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