LEADS CSF 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 *

Gauge needle used for LP *

CSF Collection

Date of Collection *

Time of Collection *

Last date subject ate *

Last time subject ate *

Collection process *

CSF Processing

Time spin started *

Duration of Centrifuge *

min

Temp of Centrifuge *

°C

Rate of Centrifuge *

x g

Total amount of CSF collected *

Time Aliquoted *

Number of 1.5 mL aliquots created (up to 14 total)(Orange cap cryovials) *

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

If applicable, specimen number of residual CSF aliquot (last four digits) *

Time aliquots placed in freezer *

Storage temperature in freezer *

°C

LEADS CSF Sample Form

Instructions for Electronic Submittal

Instructions for Fax/Email Submittal

General Information

Subject Information

CSF Collection

CSF Processing

Notes