Principal Investigator:	[Name] [Address] [Telephone number] [Email]
Contact person for queries, if applicable:	[Name] [Address] [Telephone number] [Email]
Date:
Request number: (to be issued by DZNE Brain Bank Head Office)

Herewith I/we apply for tissue samples from the DZNE Brain Bank for the following project:

Title of the project:
Summary of the project: (The summary should include background, aim, hypotheses, description of methods, if appropriate power analysis and encompass not more than 2 pages. Please make sure to provide an answer to the question ‘What and how much tissue and how many tissue samples are necessary to examine what hypothesis by using what method’?)
Preliminary work: (e.g. pilot studies, animal/tissue culture experiments, evaluation of method, validation of antibody on human tissue etc; in case of little or no preliminary work, it is advisable to separate the project into a pilot and a study phase)
Publications relating to preliminary work, if applicable:
Funding for the project:
Project duration:
Ethical approval for the project: (Please provide copy of approval letter including number and date of approval as well as contact details of the approving Ethics Committee. While an Ethical vote is obligatory for the final approval of the tissue request, it may be advisable to hold back sending the application to the Ethics Committee until a final version of the tissue request is agreed upon.)

Tissue samples are required from the following cohorts (patients and controls):

Number of patients-I: Definition1: Further specifications2:
Number of patients-II, if applicable: Definition1: Further specifications2:
Number of controls, if applicable: Definition1: Further specifications2:

Please add additional rows in case samples are required from patients with different diseases or from patients with different disease subtypes.

1e.g. ‘Alzheimer patients with Braak stage V to VI, female’ or ‘no dementia, age 60 to 70, female’

2e.g. exclusion criteria, maximal post mortem interval (specifications need to be justified through e.g. preliminary work)

Type and amount of required tissue samples (by cohort, see previous table):

Patients-I

Brain region (e.g. frontal cortex, hippocampus)	Type of tissue (e.g. cryopreserved tissue, formalin-fixed tissue, formalin-fixed and paraffin-embedded tissue)	Amount (mg or number of sections)	Further specifications (e.g. thickness of section)

Please add an additional row for each different brain region or type of tissue.

Patients-II, if applicable

Brain region (e.g. frontal cortex, hippocampus)	Type of tissue (e.g. cryopreserved tissue, formalin-fixed tissue, formalin-fixed and paraffin-embedded tissue)	Amount (mg or number of sections)	Further specifications (e.g. thickness of section)

Please add an additional row for each different brain region or type of tissue.

Controls, if applicable

Brain region (e.g. frontal cortex, hippocampus)	Type of tissue (e.g. cryopreserved tissue, formalin-fixed tissue, formalin-fixed and paraffin-embedded tissue)	Amount (mg or number of sections)	Further specifications (e.g. thickness of section)

Please add an additional row for each different brain region or type of tissue.

Required clinical data:

In case the PI has been part of the effort to collect the samples requested, please specify:

What happens after you have submitted your tissue request?

You will receive a confirmation that your request has been registered.

A colleague of the DZNE Brain Bank might get in contact with you to discuss feasibility and possible amendments of your request. This is mainly due to the limited availability of the tissue. As a result, the first and the final version of application can differ considerably.

The decision about the final version of the tissue request will be taken by the Tissue Committee of the DZNE Brain Bank.

Please be aware that prior to receipt of the tissue, you will be asked to confirm in writing to adhere to all points stipulated in the Regulations for use of the databases, data and biomaterials of the DZNE Brain Bank (‘Nutzungsordnung der Datenbanken, Daten und Biomaterialien der DZNE Brain Bank’, available on the website). Additionally, you might be asked to sign a Material Transfer Agreement. You will receive the respective documents at the appropriate time.

Please send the application by e-mail to brainbank-headoffice@dzne.de