UNIVERSITY OF TEXAS SOUTHWESTERN
ALZHEIMER DISEASE CENTER
Brain Tissue/Body Fluid Request
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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
The ADC Tissue Committee will consider your request. You will be notified regarding the Committee's action.
Use of tissue for unfunded projects will be approved for a maximum of 24 months. For additional tissue/fluid, submit a renewal request along
with a brief statement of your research progress to date. Approval of renewal request will be based upon success of preliminary
experiments/research progress to date and availability of new funding for the project.
A brief scientific proposal by the investigator requesting tissue/fluids must be attached to this form. The hypothesis, specific aims,
background and methodology should be included in the summary. The clinical information corresponding to the brain tissue/fluids needed by
the investigator should be included. The postmortem interval should also be specified. Current research funding must be included. A
curriculum vitae is needed for all persons requesting tissue/fluids who are not UT Southwestern faculty.
NOTICE: All publications resulting from the use of this tissue/fluid should acknowledge the ADC grant (AG12300) and the ADC
Neuropathology Core if using brain tissue. It is important that the ADC Publications Committee (Dr. Rosenberg, Chair) review any manuscript
reporting the results of research performed using ADC tissue/fluid resources prior to submission of the manuscript for consideration for
publication.
NAME AND TITLE OF INVESTIGATOR:
DEPARTMENT AND ADDRESS:
TELEPHONE #:
TYPE OF REQUEST:
NEW for unfunded pilot project
NEW for funded project
RENEWAL (Original request dated
FAX #:
NATURE OF FUNDING AVAILABLE OR REQUESTED FOR PROJECT:
)
Source:
Dates:
INSTITUTIONAL REVIEW BOARD (IRB)
Has this research been approved by an Institutional Review Board (IRB)? _____ Yes
If so what is the name of the IRB?
If not, give rationale for not submitting to IRB.
______No
TISSUE REQUESTED:
Describe tissue: Brain,
CSF,
Serum,
Plasma;
RBC’s;
Other
Amount of tissue requested: Brain: _____ gms.; CSF: _____cc's; Serum: _____ cc's.
Plasma____cc’s;
Clinical information needed for tissue provided
Yes
No (If yes, complete Data Request Form)
Diagnostic categories:
AD;
Aged control;
MCI;
FTD;
Other
Age range:
Sex:
Female;
Male
Sites:
Cerebral cortex,
Hippocampus,
Brain stem,
Other.
Postmortem interval:
______ hrs minimum, ______ hrs maximum
Number of specimens needed:
Earliest date by which needed:
Type of tissue:
Fresh;
Fixed;
Frozen;
Any other conditions-specify.
RBC’s_____cc’s;
NEUROPATHOLOGICAL DIAGNOSTIC STUDIES NEEDED ON CASES FROM WHICH TISSUE IS REQUESTED:
I understand human tissues/fluids may harbor disease-causing pathogens (e.g., viral hepatitis, HIV) that may remain undetected even after routine
pathological evaluation, and that all human tissues must therefore be considered biohazardous and potentially dangerous. As Principal Investigator on this
project, I acknowledge full responsibility to train any of my laboratory staff, who might be exposed to this tissue in its proper handling, use, and disposal, and
will provide documentation of such training to the ADC Tissue Committee upon request. Further, I will not transfer tissue provided to me through the ADC to
other investigators without the express permission of the ADC Tissue Committee after completion of a Tissue Request Form.
I agree to acknowledge the University of Texas Southwestern Medical Center’s Alzheimer’s Disease Center and the NIH Grant P30AG-12300
"Neurobiology of Alzheimer's Disease and Aging” in our grant submissions and original papers in which data have been derived in part from
tissue/fluids obtained from this request. I shall provide the UT Southwestern ADC this information as a condition to receive the materials requested
I will assume responsibility for any special shipping charges incurred in providing these specimens (e.g., Federal Express). My Federal Express
Account Number to facilitate shipment of the tissue is:
Principal Investigator
C/data/My Documents/Brain Request/Tissue Form.doc
Date
(Revised 11/2011)