MSBase Imaging Repository Data Request Form

Principal Investigator Details	Please provide your details as the site principal investigator. (Please ensure these details are accurate and up-to-date.)
Site ID

	*Required

Admin Contact Details	Please provide your details as the site admin contact. (Please ensure these details are accurate and up-to-date.The download link will be sent to your email.)

	*Required

Data Request Criteria
Specify the age range of subjects in years. ERROR:Max should be greater than min
Specify the gender(s) required for the study. Male only Female only All

Which sequences are mandatory for your study? (Please tick the boxes of those sequences you require.) 3D T1 Pre-contrast 3D T1 Post-contrast 3D FLAIR 2D FLAIR Other (Please specify in the comment section below if you have other requirements)
What is the numerical range of timepoints required for your study (if it is longitudinal)? (Please provide minimum and maximum values.) ERROR:Max should be greater than min
Please specify the interval between the first and last scans in months for individual subjects required for your study. (Please provide minimum and maximum values.)(This equates to planned study duration.) ERROR:Max should be greater than min
Please specify the condition for the period within which the scans were acquired. Start Date End Date
Please provide additional information or requirements regarding your request.