4RTNI2 Blood Sample Form

Please complete this form when sending 4RTNI2 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 *

Site *

Phone *

Fax

Email *

Date *

Study *

Visit *

Kit Number *

Site ID *

RAVE Number *

Family Number

Birth Year *

Sex *

FedEx Number

Collection Information

Date Drawn *

Sodium heparin tube (PBMC) drawn *

Time of Draw *

Total volume of blood drawn into 3 x 2 *

Last date ate *

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

Last time subject ate *

Blood Processing

Plasma Processing

Time spin started *

Original Volume Drawn *

Number of 0.5 mL plasma aliquots created (24-30 total) (Lavender cap cryovial) *

x 0.5mL

If applicable, volume of residual plasma aliquot (less than 0.5 mL) (Blue cap cryovial) *

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

Time aliquots placed in freezer *

Serum Processing

Time spin started (within 30 minutes of draw time) *

Original volume drawn (1x10 mL Serum tube) *

Number of 0.5 mL serum aliquots created (8-10 total) (Red cap cryovial) *

x 0.5mL

If applicable, volume of residual serum aliquot (less than 0.5 mL) (Blue cap cryovial) *