LEADS Blood Sample Form

Please complete this form when sending LEADS samples to NCRAD. The form can be submitted electronically or it may be printed and faxed.
If faxing the form, please do so as soon as possible after the sample is taken. NCRAD would like to receive this form before the sample arrives.

Fill out the form completely.
Click the 'Submit Form' button at the bottom of the page
Print a paper copy of the form to include with the physical sample when shipped

Print the static version of the form
Fill out the form by hand
Fax the form to Kelly Faber at (317) 278-1100 or email to alzstudy@iu.edu
Include the printed copy with the physical sample when shipped

( * = required field for submission )

General Information

From *

Date *

Phone *

Email *

FedEx Number

Subject Information

Study *

Participant ID *

Participant Type *

Visit *

Kit Number *

Year of Birth *

Sex *

CSF Collected *

Blood Collection

Date Drawn *

Time of Draw *

Last date subject ate *

Last time subject ate *

Blood Processing

RNA (Paxgene Tube)

Total volume of blood drawn into a 1 x 2.5 mL PAXgene RNA tube *

Time PAXgene RNA tube placed in freezer (24 hour clock) *

Serum (Red Top) Tube

Time spin started *

Duration of Centrifuge *

min

Temp of Centrifuge *

°C

Rate of Centrifuge *

x g

Original Volume Drawn *

Time Aliquoted *

Number of 1.5 mL serum aliquots created (red cap) *

If applicable, volume of residual serum aliquot (less than 1.5 mL in cap) *

If applicable, specimen number of residual serum aliquot (last four ts) *

Time aliquots placed in freezer *

Storage temperature in freezer *

°C

Plasma (Lavender-top) Tube

Time spin started *

Duration of Centrifuge *

min

Temp of Centrifuge *

°C

Rate of Centrifuge *

x g

Original Volume Drawn *

Time Aliquoted *

Number of 1.5 mL plasma aliquots created (lavender cap) *

If applicable, volume of residual plasma aliquot (less than 1.5 mL in cap) *

If applicable, specimen number of residual plasma aliquot (last four ts) *

Time aliquots placed in freezer *

Storage temperature in freezer *

°C

Buffy coat aliquot created (clear cap)

Buffy coat aliquot #1 *

(last four digits)

Buffy coat volume #1 *

Buffy coat aliquot #2 *

(last four digits)

Buffy coat volume #2 *

Buffy coat aliquot #3 *

(last four digits)

Buffy coat volume #3 *

PBMC (NaHep Green Top Tube)

Original Volume Drawn *

EDTA (Lavender Top Tube - 6mL)

Original Volume Drawn *

LEADS Blood Sample Form

Instructions for Electronic Submittal

Instructions for Fax/Email Submittal

General Information

Subject Information

Blood Collection

Blood Processing

RNA (Paxgene Tube)

Serum (Red Top) Tube

Plasma (Lavender-top) Tube

Buffy coat aliquot created (clear cap)

PBMC (NaHep Green Top Tube)

EDTA (Lavender Top Tube - 6mL)

Notes