Resource Inquiry Form

Please complete this form to request ADRC resources. A response is required to all questions

Resource recipients agree to acknowledge the Stanford ADRC in all publications and presentations that make use of these resources: "Farrukh-Jamal Stanford Alzheimer's Disease Research Center, NIH grant P30 AG066515."

1) First name of requester

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2) Last name of requester

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3) Email

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4) Contact phone number

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5) Are you the principal investigator?

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Yes No

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a. First name of principal investigator

b. Last name of principal investigator

c. Principal investigator's email

d. Principal investigator's contact phone number

6) Co-investigator

7) Institutional or company affiliation, name

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8) Institutional or company affiliation, city and state;
if not U.S., city and country

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9) Is this a collaborative effort

Yes

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9.a) Collaborators Infomation

9.b) Will there be data shared back with the ADRC

Yes

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10) Grant title or project title (if it is not for a grant)
(please provide full grant title, if applicable)

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11) Federal funding type:

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Federal

Non-federal

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12) Funding period (eg, 12/1/19-11/30/24)

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13) Study start date (dd/mm/yyyy)

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D-M-Y

14) Study end date (dd/mm/yyyy;
maximum, 5 years from date of request)

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D-M-Y

15) Funding source
(granting agency and grant number,
if applicable, or other funding source)

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16) Total grant amount

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17) Have you previously requested info?

Yes

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17.a) Any previous issues with data sent?

Yes

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17.b) What is the request before?

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18) Request DATA only

Yes

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19) Request TISSUE only

Yes

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20) Request BOTH data and tissue

Yes

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21) Request for SERA

Yes

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22) Request IMAGING (check all applicable requests)

PET

MRI

Amyloid

Tau

23) Use of DNA from NCRAD

Yes

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23.a) Add NCRAD# for any ADRC data to acknowledge NCRAD

24) Research/data/materials purpose
      (please describe what and how the data
      we provide will be used for, include
      specific aims, anticipated otucomes,
      and specific purpose of data/material
      use being requested)

* must provide value

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25) Brief description of the specific
      data elements or materials/specimen being requested
      (e.g. DATA: age, sex, MoCA score, PET imaging;
       MATERIALS/Biospecimen: Cell line, brain tissue,
      CSF, stool)

* must provide value

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26) Other comments (such as urgency of the request),
if any

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Blank copy of the ADRC DUA - click the link below to download

A signed data use agreement (DUA) will be required before data resources will be released. Please download the DUA before pressing "Submit" and send to your institutional official or legal representative for review. Once the highlighted portions are completed and the agreement is signed, the DUA can be emailed to Stanford's Office of Sponsored Research for processing (osr_intake@stanford.edu, subject line: RRA-524409). Note: due to the volume of requests and to ensure consistency among recipients, Stanford is only accepting administrative edits to the agreement (highlighted in yellow).

Attachment:stanford_adrc_dua.pdf

This Agreement between the BOARD OF TRUSTEES OF THE LELAND STANFORD JUNIOR UNIVERSITY ("Stanford"), an institution of higher education having corporate powers under the laws of the State of California, and "Recipient", a corporation having a principal place of business, is effective as of the last date of signature below ("Effective Date").

Dr. Victor Henderson ("Principal Investigator") of Stanford plans to provide the data described in Exhibit A ("Data") to Recipient for a research project described in Exhibit A ("Research Program"). The parties hereby agree as follows:

1. LICENSE GRANT

1.1 License Grant. Subject to the terms and conditions of this Agreement, Stanford grants to Recipient a nonexclusive right to use the Data solely in the Research Program, during the Term of this Agreement as set forth in Exhibit A ("Term").

1.2 License Term. Principal Investigator will make the Data available to Recipient during the Term, which Term may be extended only by advance written agreement of both parties.

1.3 No Other Rights. This Agreement does not constitute, grant nor confer any license under any patents or proprietary interests of one party to the other, except as explicitly stated herein.

2. STANFORD DATA

2.1 Ownership. Stanford retains ownership of the Data. Stanford retains all rights to distribute the Data to other commercial or non-commercial entities.

2.2 De-identification. All individually identifiable health information has been removed from Data. Data does not include "Protected Health Information" ("PHI") as defined in 45 C.F.R. Section 160.103. Should Recipient inadvertently receive Data that has not been completely de-identified, or otherwise identifies a subject, Recipient shall notify Stanford immediately and shall follow Stanford's written instructions for handling, which may include return or destruction of the identifiable information.

3. RECIPIENT USE OF STANFORD DATA

3.1 Restrictions. Recipient will use Data only for the Research Program. If Recipient desires to use or disclose any Data for purposes other than the Research Program, Recipient must obtain prior written consent from Stanford, either by an amendment to this Agreement or a new agreement.

3.2 No Further Access or Transfer. Recipient will not disclose or transfer the Data to any third party without prior written consent from Stanford.

3.3 No Re-identification or Contact. Recipient acknowledges and agrees that: (1) Recipient will not attempt to re-identify or otherwise determine the identity of any human subject or other individual who may be the subject of the Data, and will not attempt to contact any such individuals for any purpose, and (2) considerable harm may ensue if Recipient (or any recipient of the Data) intentionally or negligently allows the disclosure, release or publication of information that identifies such individuals. In the event that Recipient inadvertently receives identifiable information or otherwise identifies an individual, Recipient will promptly notify Stanford and follow Stanford's reasonable written instructions, which may include return or destruction of the identifiable information.

3.4 Data Security. Recipient will follow data security best practices for receipt, storage and use of Data, and specifically agrees that it will:

(1) implement and maintain commercially reasonable and appropriate physical, technical, and organizational security measures designed to protect the Data against accidental or unlawful loss, destruction, alteration, unauthorized disclosure or access, and all other unlawful forms of collection or use, consistent with Stanford's Minimum Security Standards set forth at minsec.stanford.edu;

(2) assist Stanford as reasonably requested to respond to requests from government authorities, data subjects, or others to provide information (including details of the activities performed by Recipient) related to Recipient's processing of the Data;

(3) Only process the Data on its systems or facilities to the extent necessary to perform its obligations contemplated by the parties under this Agreement.

(4) maintain reasonably accurate and up-to-date logs and records of the processing of the Data;

(5) not lease, sell, distribute, or otherwise encumber the Data for any purpose; and

(6) promptly notify Stanford of any investigation, litigation, arbitrated matter, or other dispute relating to Recipient's security or privacy practices as it may directly and materially relate to Recipient's performance of its obligations to Stanford under this Agreement.

3.5 Notice of Data Incidents. Recipient shall without undue delay (within 48 hours of confirmation) notify Stanford if any of the following occur:

(1) any unmitigated, material security vulnerability, or weakness of which Recipient has actual knowledge, in either Stanford's or the Recipient's systems or networks that has compromised the Data;

(2) any successful, imminent or significant threat of unauthorized access, use, disclosure, breach, modification, theft, loss, corruption or destruction of information, or any interference with information technology or system operations, that negatively impacts the confidentiality, integrity, and availability of the Data; or

(3) any known failure or inability to maintain material compliance with requirements of this Agreement or any applicable law.

3.6 Reporting. In consideration of Stanford having provided Data, Recipient will report the results of its research with Data to Principal Investigator.

3.7 Compliance with Law and Policy. Recipient's use of Data will comply all applicable federal, state and local laws and regulations, including those of the NIH, FDA, or DHHS, and the Code of Federal Regulations for the protection of human subjects (45 CFR 46.102). In addition, Recipient represents and warrants that all relevant Recipient or institutional policies have been followed, including the completion of any IRB or ethics review or approval that may be required.

4. PUBLICATION

Any publication or presentation of results will appropriately cite the contributions of Stanford and the Stanford Alzheimer's Disease Reearch Center (ADRC, NIH grant P30 AG066515) using customary standards of scientific attribution. Each party will provide the other with publications or presentations of previously unpublished results thirty (30) days before submission for presentation or publication, to enable the other party to identify and request removal of its confidential information and to seek patent protection, if applicable.

5. GENERAL PROVISIONS

5.1 Publicity. Neither party will use the name or trademark of the other party, or the names of the other party's employees, students or agents in any publicity, advertising or announcement related to this Agreement without the prior written consent of the other party's authorized officials.

5.2 No Warranties. Data are provided by Stanford AS IS, WITHOUT ANY WARRANTIES, EXPRESS OR IMPLIED, INCLUDING WITHOUT LIMITATION ANY WARRANTY OF FITNESS FOR A PARTICULAR PURPOSE.

5.3 Liability. In no event shall Stanford be liable for any use by Recipient of Data or results or for any loss, claim, damage, or liability, of any kind or nature, that may arise from or in connection with this Agreement or Recipient's use, handling, or storage of Data. Recipient agrees to indemnify and hold harmless Stanford, its trustees, officers, employees, students, volunteers and agents from all liability, loss, or damage they may suffer as a result of claims, demands, costs or judgments against them arising out of the use, handling or storage of Data or results by Recipient.

5.4 Termination. Either party may terminate this Agreement at any time upon thirty (30) days prior written notice. Within thirty (30) days after the effective date of termination, Recipient will discontinue all use of the Data and related information, and return or destroy the Data in accordance with Stanford's instructions. Sections 2.1, 3.1 to 3.7, 4, 5.1, 5.2 and 5.3 will survive the termination or expiration of this Agreement.

5.5 Notice. All notices under this Agreement are deemed fully given when written, addressed, and sent as follows:

All notices to Recipient are e-mailed or mailed to:

Please print/save a PDF of this request form and forward to your institutional official along with your downloaded DUA. Please also include a copy of this PDF form when inquiring about the status of your request. You may send inquiries to: bschuele@stanford.edu (cc: jhwang01@stanford.edu and askarin@stanford.edu).

Recipient first name

* must provide value

Recipient last name

* must provide value

Recipient address

* must provide value

Recipient email

* must provide value

Principal place of business (if applicable)

All notices to Stanford are e-mailed or mailed to:

Office of Research Administration
485 Broadway, Floor 3
Redwood City, CA 94306
Reference: RRA-524409
Osr_intake@stanford.edu
cc:askarin@stanford.edu; bschuele@stanford.edu

5.6 Severability. If any paragraph, term, condition or provision of this Agreement is found by a court of competent jurisdiction to be invalid or unenforceable, or if any paragraph, term, condition or provision is found to violate or contravene the substantive laws of the State of California, then the paragraph, term, condition or provision so found will be deemed severed from this Agreement, but all other paragraphs, terms, conditions and provisions will remain in full force and effect.

5.7 Integration. This Agreement, including attached Exhibits, supersedes all prior oral and written proposals and communications, if any, and sets forth the entire agreement of the parties with respect to the subject matter hereof, and may not be altered or amended except in writing, signed by an authorized representative of each party.

5.8 Electronic Copy. The parties to this document agree that a copy of the original signature (including an electronic copy) may be used for any and all purposes for which the original signature may have been used. The parties further waive any right to challenge the admissibility or authenticity of this document in a court of law based solely on the absence of an original signature.

The duly authorized party representatives execute this Agreement.

Recipient signature

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Add signature

Recipient name

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Recipient title

* must provide value

Date

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M-D-Y

If you are the recipient, please submit the form now and leave the below sections blank.

Board of Trustees of the Leland Stanford Junior University

Signature

Add signature

Name

Title

Date

M-D-Y

I acknowledge that I have read this Agreement in its entirety and will use reasonable efforts to uphold my obligations and responsibilities under this Agreement.

Principal Investigator

Signature

Add signature

Name

Title

Date

M-D-Y

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