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)

           

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

Download the complete PDF Package here .

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

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(Limit 100 Characters)
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(Limit 75 Characters)

Principal Investigator

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Business Contact Information

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Attachments

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USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
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