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Campus-MichiganADC

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If you are a staff or faculty member and have a request for Data Core that is for participants or secondary data analysis, please complete the following information.

If you are an MADC staff or faculty member not looking for potential study participants or data to perform secondary data analysis, please complete a Data Core Service Request form here.

Please complete all fields below. If you have other comments, there is a field for notes at the end. Thank you!

Please complete the following information about yourself before moving on to the data request itself.

Form Date (mm/dd/yyyy)

What is the home institution of the Principal Investigator and study IRB?

If the institution is 'Other', please specify:

Additional Information:

If the institution is any other than the University of Michigan, a Data Use Agreement will be required. Please contact Arijit Bhaumik (Research Administrator; 734-936-8281, arijit@med.umich.edu) after completing this form to initiate the process for this agreement. Investigators from Wayne State University and Michigan State University who are listed on the University of Michigan Memory and Aging Project (UM-MAP) IRBMED:HUM00000382 or on the UMMAP-Wayne State IRB do not require a DUA.

Role that best describes your position:

You selected "Other", please describe:

Who is your faculty advisor or supervisor?

Country

Specify Other Country

Address

City

State

Zip Code

Data Requested

I'm looking for...

Please upload your study details including:

1. Project Title
2. Hypotheses
3. Analytic Plan
4. Power Analysis
5. Key References
6. Future Plans for Funding
7. Project Timeline (Including Start and Anticipated End Date)
8. IRB Number
9. Principal Investigator Name

These items can be completed on our template and attached to this Request at the bottom of this form:
https://alzheimers.med.umich.edu/wp-content/upl...

Project Title

What criteria do these individuals have to meet?

Certain diagnosis

Certain age minimum or maximum

Certain racial/ethnic background

Completed or eligible and interested for an MRI/PET Scan

What diagnosis?

Normal Cognition

Mild Cognitive Impairment

Alzheimer's Disease

Other Dementia Diagnosis

Please describe what 'Other' dementia diagnosis you are referring to.

Which of the following subcategories of MCI? (Check all that apply)

Amnestic

Non-Amnestic

What amnestic domain?

What non-amnestic domain(s)? Check all that apply.

Language

Attention

Executive

Visuospatial

What's the minimum age in years (if any)? If no minimum, write "None".

What ethnic background?

Hispanic only

Non-Hispanic only

Either Hispanic or not

What race(s)? (Check all that apply)

White/Caucasian

Black/African American

Asian

Native Alaskan/Pacific Islander

MRI, PET, or both?

Completed an MRI or eligible and interested?

What other demographic characteristics are you interested in? (Check all that apply)

Gender

Years of education

Marital status

Current living situation

Current level of independence

Handedness (i.e., dominant hand)

Anything else or other notes (e.g., Only requesting left-handed females who live independently)

What data are you interested in obtaining? Check all that apply

Note: please consult NACC's data dictionary at the following link: https://www.alz.washington.edu/WEB/forms_uds.html

What data are you interested in obtaining? Check all that apply

Family History (NACC A3)

Current Medications (NACC A4)

Health History (NACC A5)

Physical Evaluation Form (NACC B1)

Clinical Dementia Rating (NACC B4)

Neuropsychiatric Inventory (NACC B5)

Geriatric Depression Scale (NACC B6)

Functional Assessment (NACC B7)

Neurological Examination (NACC B8)

Clinician Judgement of Symptoms (NACC B9)

Neuropsychological Battery (NACC C2)

Medical Conditions (NACC D2)

Would you like data in wide format, long format, or both formats?

Wide

Long

Both

Example of wide:

ID	X_Visit_1	Y_Visit_1	X_Visit_2	Y_Visit_2
1	1.5	1.0	2.5	3.0

Example of long:

ID	Visit	X	Y
1	1	1.5	1.0
1	2	2.5	3.0

Do you need contact information for these participants?

Which Contact Information (Check all that apply)?

Name

Full Address

Zip Code

Country

Phone Number

Email Address

Study Partner Relationship

Study Partner Name

Study Partner Full Address

Study Partner Zip Code

Study Partner Country

Study Partner Phone Number

Study Partner Email Address

Is there anything else you would like us to know about regarding this request?

The full details of a ticket, including any appropriate circumstances or supplementary information that may aid in resolving it.

Press Alt + 0 within the editor to access accessibility instructions, or press Alt + F10 to access the menu.

Terms of Agreement

Would you like one of our analysts to reach out to you?

Please note that we offer statistical services available under the direction of Kelly M. Bakulski, PhD.
https://sph.umich.edu/faculty-profiles/bakulski...

I, the data requestor, agree not to use or disclose the information other than permitted by the agreement or otherwise required by law.

Enter your name in this field as your signature.

I, the data requestor, agree to use appropriate safeguards to prevent the use or disclosure of the information (including PPI/PHI), except as provided for in the agreement, and require the recipient to report to the covered entity any uses or disclosures in violation of the agreement of which the recipient becomes aware.

Enter your name in this field as your signature.

I, the data requestor, hold any agent of the recipient (including subcontractors) to the standards, restrictions, and conditions stated in the data use agreement with respect to the information.

Enter your name in this field as your signature.

I, the data requestor, will not identify the information or contact the individuals (Please initial).

I, the faculty advisor/supervisor, agree to the terms listed above.

Enter your name in this field as your signature.

BY ENTERING YOUR INITIALS, YOU ARE AGREEING TO THE CONFIDENTIALITY AGREEMENT PROVIDED ON THE FIRST PAGE, TO FOLLOW THE STANDARD OPERATING PROCEDURES FOR DATA REQUESTS, AND TO ACKNOWLEDGE PARTIAL SUPPORT FROM THE MICHIGAN ALZHEIMER'S DISEASE CENTER NIH/NIA GRANT 5P30AG072931 IN ALL WORKS PRODUCED USING THIS DATA

Enter Initials in this box:

Attachment

File attachments associated with the ticket.

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Other Fields

Your name

Your first name

Your last name

Your email address