CDC - Amyotrophic Lateral Sclerosis: Research Application Form

National Amyotrophic Lateral Sclerosis (ALS) Registry

National Amyotrophic Lateral Sclerosis (ALS) Registry Research Application Form
		Form Approved OMB No. 0923-0041 Exp. Date 01/31/2023


* Required Fields

Type of Request* (Mark all that apply)

Research notification Data Biospecimens or tissues

To start the application process, please download and complete the National ALS Registry Research Application Form.

Download the complete PDF Package here .

Download files in MS Word format. All applications using MS Word must be emailed to als@cdc.gov
National ALS Registry Research Application Form Part A Part B Part C Part D

Before submitting your application, please attach a copy of the following required materials in the web form on the application page. All materials received by the Agency for Toxic Substances and Disease Registry (ATSDR) have to be in pdf format.

Research Application Form and signed Researcher Agreement.
Cover letter with a brief overview of the project, highlighting the importance of the research proposal.
PI CV or Biosketch.
Full study protocol, including consent form and all survey instruments.
Confirmation of IRB approval of full protocol and informational materials.
Additional supporting documents.

For clinical notifications include the recruitment letter and/or informational materials to be sent to potential study participants and complete Part A.
For specimens include completed specimen request form(s) (Part B) and/or (Part C) including types and number of specimens requested.
For data only complete Part D.

Research Submission Form

Title of the Study:* (Limit 100 Characters)
Short Title of Study:* (Limit 75 Characters)
Principal Investigator
First Name:*		Last Name:*
Title:*
Business Contact Information
Business Address 1:*		Zip Code:*
Business Address 2:		Phone:*
City:*		Email:*
State:*
Attachments

Research Application Form :
Research Application Part A:
Research Application Part B:
Research Application Part C:
Research Application Part D:
Cover Letter:*
PI CV or Biosketch:*
Full study protocol, including consent form and all survey instruments:*
Recruitment letter/informational materials:*
Confirmation of IRB approval of full protocol:*
Confirmation of IRB approval of informational materials:
Additional supporting document:

CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0041).

National Amyotrophic Lateral Sclerosis (ALS) Registry

National Amyotrophic Lateral Sclerosis (ALS) Registry Research Application Form

Research Submission Form

File Formats Help: