Application for Biospecimens

OMB#: 0925-0766 Expiration date: 09/2026

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0766). Do not return the completed form to this address.

First Name

Last Name

Phone Number

Institutional affiliation

Institutional address

City

State

ZIP code

Country

Check which disease type you are interested in accessing biospecimens from. You may check more than one box.

For information on each of the following disease types you are interested in requesting biospecimens for please see the following information pages:

Note: For access to Parkinson’s disease biospecimens, please see the PD BRAC website and its associated webform.

For questions regarding the NINDS BRAC process please contact NINDS-BRAC@ninds.nih.gov.

The Huntington’s Disease Biospecimen Resource Acquisition Committee (HD-BRAC) will review applications received and provide feedback to all applicants. For more information about the application process, please visit the HD Biosample Access page. For questions regarding the BRAC process please contact NINDS-HD-BRAC@ninds.nih.gov.

You will need to submit the following as part of this web form (accepted file formats are .jpg, .jpeg .png, and .pdf):

Biosketch
Research Strategy (pdf, 38 kb) - (4 page limit)
Table Summary of Samples of Interest (pdf, 153 kb) - (This should include information on sample availability)

Application Title

If applicable, please match the biosample request title to the title for the corresponding existing or planned grant application.

Applicant (Primary) and Institution Information

Biographical Sketch

Please upload a copy of your Biographical Sketch.
File Limit: 1
File Size Limit: 2 MB
File Types: gif jpg jpeg png pdf.

Would you like to submit a biographical sketch for (an) additional investigator(s)?

Yes

Additional File

File Limit: 3
File Size Limit: 2 MB
File Types: gif jpg jpeg png pdf.

Research Strategy (4-page limit)

Rationale and Background

File Limit: 1
File Size Limit: 2 MB
File Types: gif jpg jpeg png pdf.

Project Support

NIH funding support

Do you currently have NIH funding to support this research project?

Yes

NIH Funding Institution

Please indicate the NIH Funding institute (i.e. NINDS) from which you have received funding.

Grant Number

Funding Sources

Briefly describe the source of funding to support your proposed project.

Project Support

If you do not have funding, please explain your plan to apply for funding.

Letter of Support

Do you require a letter of support for this application?

Yes

Grant Submission Due Date

Please provide the due date for this grant submission

Table Summary of Samples of Interest

Table Summary

File Limit: 1
File Size Limit: 2 MB
File Types: gif jpg jpeg png pdf.

Biosamples/tissue/data requested in a table: In a table, briefly outline the number, type, and amount of biospecimens/tissue requested, including subject type (e.g. HD, control, any specific clinical parameters), visit number (if applicable), volume of sample required, and the cohort or biorepository through which the biosamples are currently available. In addition, the applicant should determine if the samples required are available through the repository prior to submitting an application.