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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.

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.

Data Requested

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...
What criteria do these individuals have to meet?
What criteria do these individuals have to meet?
What diagnosis?
What diagnosis?
Which of the following subcategories of MCI? (Check all that apply)
Which of the following subcategories of MCI? (Check all that apply)
What non-amnestic domain(s)? Check all that apply.
What non-amnestic domain(s)? Check all that apply.
What ethnic background?
What ethnic background?
What race(s)? (Check all that apply)
What race(s)? (Check all that apply)
What other demographic characteristics are you interested in? (Check all that apply)
What other demographic characteristics are you interested in? (Check all that apply)
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
Would you like data in wide format, long format, or both formats?
Would you like data in wide format, long format, or both formats?

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
Which Contact Information (Check all that apply)?
Which Contact Information (Check all that apply)?
The full details of a ticket, including any appropriate circumstances or supplementary information that may aid in resolving it.

Terms of Agreement

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.
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.
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.
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 5P30AG053760 IN ALL WORKS PRODUCED USING THIS DATA.
File attachments associated with the ticket.
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Other Fields

Your name