I am requesting access to the Dystonia Coalition data/samples described in this form for the research purposes described. I agree to follow the policies described in the Dystonia Coalition Constitution and Bylaws document with regards to these data/samples. I have been provided a copy of that document and have read it. In particular, I have read through the ‘Data and Resource Sharing’, ‘Authorship, Acknowledgements, and Reporting’, ‘Copyright and Patent’, ‘Specific Terms and Conditions for Resources Provided through the Dystonia Coalition’, ‘Protection of Human Subjects in Research’, and ‘Conflict of Interest’ sections.
My institution and at least one investigator at my institution have signed the Dystonia Coalition Constitution, Bylaws, Terms & Conditions document and I agree to follow the policies outlined there.
Investigators Statement of Agreement
By signing below I acknowledge that I have carefully read this document and agree:
To abide by the guidelines for accessing and using data or materials outlined above.
To not distribute or communicate any privileged information without consent of the Executive Committee. Privileged information may include findings from unpublished studies or presentations by any and all members of the DC.
Grant Number: Funding Period: Resources being requested(check all that apply):
Data Video Samples (how much DNA?) ___________________
Specific data requested:
Subject criteria: (e.g., “cervical dystonia subjects, ages 18-45, all female, no family history of tremor”, “all cervical dystonia subjects with BDI-II completed”, “all subjects with task specific dystonia reported”)
Age range: Age at onset range: Gender: Male Female
Which data sets? (check all that apply): BR NH-ES NH-LS