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IvdSDqnZV5KWj3qdDCqg4M53R8qZTuYJp8immsAMCM

Rosamund Stone Zander Translational Neuroscience Center (RSZ TNC) Service Intake Form

Together, the cores and services of the RSZ TNC provide infrastructure for basic scientists and physicians to collaborate in bringing discoveries from bench to bedside. The goal of the RSZ TNC is to improve the lives of all children with brain disorders by fostering timely and efficient translational research based on the core principles of scientific rigor, collaboration, transparency, diversity, equity, inclusion, belonging, and access.

Please note, our service intake form has moved to a new location. Please use the link below to access the new RSZ TNC Service Request Form:

https://app.smartsheet.com/b/form/731c195a36124067a651230dff3ac4da

Thank you!

Today's Date (hidden autofill for reporting)

Y-M-D

This survey will help the RSZ TNC understand what kind of services will be needed for any new projects requesting support.

It takes about 5-10 minutes to answer these questions.

For service inquiries from the Human Neuron Core (HNC), please contact NeuroCore@childrens.harvard.edu directly (do not fill out this survey), and allow up to two weeks for a response.

Name of person requesting RSZ TNC services (Last name, First name)

Name of person submitting this form if different from above (Last name, First name)

Anticipated project start date

Email address of person requesting RSZ TNC services

Phone number of person requesting RSZ TNC services

Institution/Company Name

Department/Division

Neurology

Developmental Medicine

Genetics & Genomics

Psychiatry

Neuroradiology

Neurosurgery

Emergency Medicine

Newborn Medicine

Other

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BCH Principal Investigator name if different from requester (Last name, First name)

Are you (or your Principal Investigator) an IDDRC investigator?

Yes

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Besides the BCH PI, are there any other BCH collaborators you've been in contact with about this project?

Title of project

Is this project a Clinical Trial?

Yes

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Disorder(s) being studied

Autism Spectrum Disorder (ASD)

Cerebral Palsy (CP)

Chopra-Amiel-Gordon Syndrome (CAGS)

CDKL5 Deficiency Disorder

Down Syndrome

Fragile X Syndrome

Hereditary Spastic Paraplegia (HSP)

Kleefstra Syndrome

MECP2 Duplication Syndrome

Muscular Dystrophy

Phelan-McDermid Syndrome (PMS)

PTEN Hamartoma Syndrome (PHTS)

Rett Syndrome

Spinal Muscular Atrophy (SMA)

Sturge Weber Syndrome (SWS)

Succinic Semialdehyde Dehydrogenase Deficiency (SSADH)

SYNGAP1-Related Disorder

Tuberous Sclerosis Complex (TSC)

Other(s)

Please include a project summary describing the hypothesis, aims, background/rationale in support of study, brief description of the primary methods, and intended use of data/samples

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Is this the PI's first clinical trial or research project?

Yes

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Will this project be filing an IND/IDE with the FDA?

Yes

Project is exempt

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Type of RSZ TNC services requested (Check all that apply)

Biomarkers Unit

Clinical Research Operations and Regulatory Affairs

Data Organization Collaboration Service (DoCS)

Human Neurobehavioral Core Service

Human Neuron Core

Medicinal Chemistry Core

Translational Genomic Medicine Core

Help planning an event

Other

Clinical Research and Regulatory Affairs Service (Check all that apply)

Project consultation

Protocol development including trial/study design

Regulatory guidance

Project management

Study staff training/support

Patient recruitment

Trial monitoring

Other

Human Neurobehavioral Core Service (Check all that apply)

Project consultation

Protocol development including study design and assessment development

Performing direct neurobehavioral assessments

Training

Other

Biomarkers Unit (Check all that apply)

Project consultation

Protocol development including biomarker design

Research EEG (Human)

Animal EEG

Eye tracking

Research MRI

Data management/analysis

Other

Human Neuron Core (Check all that apply)

Project consultation

Sample collection

Differentiation

Phenotyping

Assay development and Drug screening

Repository processing

Repository storage

Other

If requested Sample Collection from the Human Neuron Core, please provide more detail be choosing from the options here:

Obtain informed consent

Collect skin biopsy and process fibroblasts

Collect blood sample and process PBMCs

If requested Differentiation from the Human Neuron Core, what is the source of iPSCs for differentiation?

Following up from the previous question on differentiation, how many lines are available?

If requested Phenotyping from the Human Neuron Core, is there a known phenotype in human iPSC-derived neurons? Rodent neurons? If so, what is it?

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If requested Assay Development and Drug Screening from the Human Neuron Core, is there a known phenotype in human iPSC-derived neurons? Rodent neurons? If so, what is it?

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Please describe the clinical synopsis of the proposed patient group

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Translational Genomic Medicine (Check all that apply)

Genomic medicine consultation

Variant analysis/interpretation/sequencing project

Multi-disciplinary clinic development

Genomic project management

Training

Other

Medicinal Chemistry Core (Check all that apply)

Project consultation

Chemical structure literature evaluation

Preclinical pharmacokinetics experiments

Sourcing of tool compounds or libraries

Screening hit follow up

Structure activity relationship (SAR) project

Drug discovery project

Other

What type of project is this?

Clinical drug trial

Clinical device trial

Biomarker study

Behavioral intervention

Outcome study

Natural history studies

Other

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Funding Source (Check all that apply)

Industry sponsored

Investigator initiated/BCH

Grant supported (Foundation/Government)

Division/Departmental funds

Other

Funding Status

Committed

Pending

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Additional information (Please specify)

Please provide any relevant materials including protocol, consent form, sponsor information, funding, etc.
Please send to tnc@childrens.harvard.edu

This form will be reviewed by the Rosamund Stone Zander Translational Neuroscience Center Executive Team and you will be re-contacted within one month of submission.

(Admin only) Reviewed by:

(Admin only)

Is this an RSZ TNC approved service request (Y/N)?

OR:

Is Administrative Review needed to approve this request?

Yes

Administrative Review is needed to approve this request

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(Admin only) Who will complete this Administrative Review?

Admin Review by Core

Admin Review by RSZ TNC Executive Team

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(Admin only) Additional comments:

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.