PSDC Blood Sample Form

Please complete this form when sending PSDC 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 *

Phone *

Email *

Date *

Study *

PIDN *

Visit *

Kit Number *

Site ID *

Birth Year *

Sex *

FedEx Number

Collection Information

Date Drawn *

Sodium heparin tube (PBMC) drawn *

Time of Draw *

Original volume of blood drawn into 3 x 2.5ml PAXgene^TM RNA tubes *

Last date ate *

Were the PAXgene^TM tubes the last tubes drawn? *

Last time subject ate *

Blood Processing

Plasma (EDTA/Lavender Top Tube) Processing

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 (8-10 l) (Lavender cap cryovial) *

x 1.5mL

If applicable, volume of residual plasma aliquot s than 1.5 mL) (Blue cap cryovial) *

If applicable, specimen number of residual plasma uot (last four digits) *

Buffy coat aliquot created (one per EDTA tube) (Blue cryovial) *

Time aliquots placed in freezer *

Serum (Serum Separator/Red Top Tube) Processing