UTSW Alzheimer S Disease Center (ADC) Data Request Form

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
o / o / o / o / o / _____
What demographics are desired? / o Age oGender oOther (specify)
Imaging
Imaging Data Desired? / o Propose using already acquired data o Proposing using new scans
For new scans, please indicate what sequences you propose. We request that the following sequences from our ADC protocol be acquired and deposited in the ADC neuroimaging database as part of your study. Any omissions will need justification. Our standard 3T MRI protocol consists of the following sequences: / ______
______
______
______
______
______/ MPRAGE sense
ADNI high-resolution T1
T2 sense
T2 FLAIR
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
Please indicate the tests of interest and desired data: / o Data already in database o Frozen samples for new assays
o New sample collections to assay
Blood / o Yes o No
CSF / o Yes o 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? / o Yes o No
Neuropsychiatric and global function variables
Mood (Geriatric Depression Scale) / o Yes o No Specify: ______
Behavior: (NPI) / o Yes o No Specify: ______
Function: (CDR, FAQ, TFLS, etc) / o Yes o 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 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