Application Form



Download 60.29 Kb.
Date conversion28.05.2018
Size60.29 Kb.

Meibergdreef 47

1105 BA Amsterdam

The Netherlands


T +31 20 566 54 99

F +31 20 691 84 66

www.brainbank.nl


Application Form

Project number: 2018/


Date :


Name Applicant :

Institute :

Department :

Street + number :

Postal code and city :

Country :

Phone :

Email address :



Shipping information

Courier of choice :

Account number :

Shipping address :


(if different from above)
Title of the research project:

Principal investigator:

Participants/cooperations:

Name: Institute:



Summary of the project (150 – 500 words excluding references)

Please include:

1. background, 2. hypothesis, 3. work plan including techniques and a motivation why you need the number of samples you are requesting and 4. references to own and other relevant work in this line of research.

* In case a more elaborate project description is present, for instance as presented to a financing institution, please enclose as an attachment.
Duration of the project:
Information on requested material

1. Diagnosis (incl. criteria and possible stages, e.g. Braak stages):




  1. Number of patients:

  2. Brain samples (precise anatomical boundaries):

  3. Treatment of tissue (fixation, freezing, medium, etc.):

  4. Maximum post mortem delay:

  5. Age range and gender:

2. Controls (incl. exclusion criteria)




  1. Number of controls:

  2. Brain samples (precise anatomical boundaries):

  3. Treatment of tissue (fixation, freezing, medium, etc.):

  4. Maximum post mortem delay:

  5. Age range and gender:


Only applicable to requests for tissue from donors with a psychiatric diagnosis:

Available clinicopathological information

All material will be accompanied by a clinicopathological report and a summary of the medical history of the selected donors (including clinical diagnosis, cause of death, medical drug history and information on several antemortem and postmortem parameters). For some donors with a psychiatric diagnosis (those who have participated in research during life), additional antemortem data is available (e.g. diagnostic phenotyping (questionnaires), brain imaging data, genetic information, biomarkers).


Would you like to be informed about the possibilities for obtaining such additional data, if available?

Yes No
Status of the project

  1. Has ethical approval been obtained for the proposed project?


  2. Has the scientific quality of the proposed project been judged, or will it be judged? If yes, please specify by whom and with which result.


  3. Is the project internally or externally funded and, if externally, by whom and for which period?


  4. The material may not be transferred to others without the NBB’s permission. However, it is permitted to temporarily send the material to another laboratory to conduct a certain analysis when this is required for good conduct of the research project, after this has been explicitly requested to the NBB. Is it necessary for your research to send the material to another laboratory or to someone who is not under your direct supervision?

    Yes No

  5. If yes, please specify the reason, the name of the laboratory, and the responsible person to whom you intend to send the material.

Reason:

Laboratory:

Person responsible:


  1. Will the project be executed in order of and/or in cooperation with a for-profit organization? If yes, please specify which organization.


  2. Have brain samples been requested from other brain banks? If so, please indicate the brain bank(s) and number and type of samples.


Further comments

Suggested precautions for handling human brain tissue

Postmortem human tissue and fluids may contain highly infectious agents and have potential risks of diseases that are highly communicable to other humans. All such tissue and fluids should be trea­ted as being a risk for such transmissi­on and handled carefully. Studies have shown several extreme­ly hazardous agents (viruses, bacteria, prions) to be very stable. The Creutzfe­ldt-Jakob (CJD) prions, for example, remain transmissible even after 30 years of tissue fixation. The agent has also been shown to withstand conventional autoclaving. Although rela­tively rare, there is no quick screening method for such agents, and adequate caution must be exercised.


We recommend to handle non-fixed tissue under a biohazard hood with all personnel taking special care. Any waste material should be treated as a biohazard and discarded according to your institution's policy for handling such material, i.e. auto­claving.

Requirements for tissue recipients

The NBB only supplies tissue, CSF and plasma (Material) that has been obtained on the basis of informed consent of the brain donor. Informed consent restricts the use of the Material to scientific

research purposes only. The Material shall only be supplied under the conditions stated in a Material Transfer Agreement (MTA), that needs to be signed by the person who is granted the power of representation within your organization. The MTA states the rights and obligations of the Provider as wel as the Recipient with regard to the Material and its use.

Contact information

In case you need further information or have questions concerning the application form or availability of tissue, please don’t hesitate to contact us or look at our website (www.brainbank.nl). Please return the completed application form to eNBB@nin.knaw.nl.




Department of the Netherlands Institute for Neuroscience, an institute of the Royal Netherlands Academy of Arts and Sciences (KNAW)




The database is protected by copyright ©dentisty.org 2016
send message

    Main page