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Required format:

WUgXoHJ8z9yo5yKy8aNazpmUjNDip8gvxGF4BAiwQck6QnsdRHgfzxqQ5W5cpisbeyYFxPQRBPA23rED2tKFEd9gDCSQqSG

Application for Access to RI-CART Data and the Recruitment Registry

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In order to equitably honor investigator requests from our data repository, please provide the information requested below.

Please note:

RI-CART is committed to supporting research by providing qualified researchers access to data and opportunities for participant recruitment. Funded studies are expected to contribute to the costs of this core resource. Costs are determined based on the nature of the request and should be discussed with the RI-CART leadership team. For labs or researchers without current funding (e.g., students, pilot studies, etc...), RI-CART will work to support access to data and recruitment as resources allow.

Date of this Request:

* must provide value

M-D-Y

Data Needed By:

M-D-Y

Name of Requester

* must provide value

Please attach biosketch:

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Upload file

Institution:

Department:

Address:

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Phone:

Fax:

Email:

* must provide value

Project Title:

* must provide value

Please choose the type of request you are making:

* must provide value

Please attach a 1-2 page protocol including introduction, abstract, purpose, preliminary data, methods, analytical plan. An IRB-approved protocol can be used as a substitute.

Upload file

Please attach a copy of your IRB submission or evidence of approval.

Upload file

Please describe the inclusion criteria for the sample you are requesting:

* must provide value

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Please describe the exclusion criteria for the sample you are requesting:

* must provide value

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What is the number of participants you are looking to recruit over what time period?

* must provide value

Do participants receive compensation?

* must provide value

Yes

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What do participants receive as compensation?

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Is there a funding source for this project?

* must provide value

Yes

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Funder:

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Grant Number:

Is funding active?

Yes

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Funding period:

From:

M-D-Y

To:

M-D-Y

Grant or project title:

Principal Investigator:

* must provide value

Institution receiving the funds:

Additional funder:

Grant number:

Is funding active?

Yes

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Funding period

From:

M-D-Y

To:

M-D-Y

Grant or project title:

Principal Investigator:

Institution receiving the funds:

How much time will be required of each participant (total hours over what period of time, e.g., 2 hours weekly for 4 weeks)?

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Is this study longitudinal?

* must provide value

Yes

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If longitudinal, how frequently and for how long will participants be followed?

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Will anyone else be involved in the project?

* must provide value

Yes

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Name of additional person involved:

* must provide value

Name of additional person involved:

Will you be sharing or sending these materials/data to anyone outside your immediate research team/lab/office?

* must provide value

Yes

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HIPAA regulation only allows us to grant approval by your lab/office/staff.

Please identify who will receive RI-CART research information and for what reason.

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How would you like to receive your data?

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Software that you use:

Version of software that you use

Data should not be shared with outside individuals or institutions. Data can only be used as approved to the Requester.

Acknowledgement of the RI-CART contribution in publications and grant proposals is required.

One copy of all submitted publications and abstracts using RI-CART resources with the cover letter to the publication editor should be sent to the RI-CART research committee.

One copy of all final publications (book chapters, journal articles etc) and abstracts using RI-CART resources is to be submitted to the RI-CART research committee.

Investigators recruiting through RI-CART agree to the following conditions:

Investigators agree to forward phenotypic data for RI-CART participants including cognitive measures (e.g., IQ, language assessments) and autism symptom measures (e.g., ADI, ADOS).

Investigators agree to refer participants to RI-CART if those participants have not previously been enrolled in RI-CART (e.g., participant recruited from another referral source).

Investigators agree to provide regular reports on which RICART-referred participants were contacted (yes/no) and the status of their consent (consented/declined/excluded).

At the end of the project, Investigators agree to provide a summary report of RI-CART participants who have participated.

I agree with the above Reporting and Data Use Requirements.

* must provide value

Yes

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Your name:

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Date:

* must provide value

M-D-Y

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