Data Request Form

Please enter the following information in regards to your GMHS data request. Note that you may only request data from one study per request (i.e., a second request would be required for data from a separate study).

Your request will be reviewed by the GMHS Research Program Manager and/or Data Manager, and delivered to you within two weeks.

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

Note: To request data for the DTI study, please use the Slaight Centre Data Request Form.
Specific requests for raw and/or processed MRI imaging data can be made using Kimel's MRI Data Request Form.

Date of request:

* must provide value

D-M-Y

Is this a new request or a request to update a data set from a previous request made using this form?

Note that updated data sets will contain identical variables as the previous request. Only records will be updated.

* must provide value

New request

Update data set

reset

Date of original request:

* must provide value

D-M-Y

Your first name:

* must provide value

Your last name:

* must provide value

Your email address:

* must provide value

Occupation or job title:

* must provide value

Please specify your occupation or job title:

* must provide value

Affiliation:

* must provide value

Please specify your affiliation:

* must provide value

CAMH Department/Unit:

* must provide value

Please specify the CAMH Department/Unit:

* must provide value

______ Department/Unit:

* must provide value

Name of the CAMH PI that you are collaborating with:

* must provide value

Email address of the CAMH PI that you are collaborating with:

* must provide value

Will individuals other than yourself have access to this data?

* must provide value

Yes

reset

Please list all individuals who will have access to the data:

* must provide value

Expand

How do you intend to use the requested data?

* must provide value

Name of scientific meeting:

* must provide value

Please specify intended journal:

* must provide value

Provide supervisor's name:

* must provide value

Grant name:

* must provide value

Please briefly describe your project / specify how you intend to use the requested data:

* must provide value

Expand

Please select the study for which you are requesting data:

* must provide value

PACt-MD

PAS-MCI

StaN

tTED

CREAtE

SenDep

Remote tDCS and CR study

TDRA Intake Form Research Database

Other GMHS Study (not listed here)

reset

Please select the study for which you are requesting data:

* must provide value

COGBD

LLS

CBSST

CCNA-tDCS

CR-LLS

Collaborative Care

MBSR + tDCS

PAS-AD

rTMS AD

tDCS LLD

tDCS at Home

Other GMHS Study

reset

Please specify which PACt-MD dataset:

* must provide value

PAC01 - PACt-MD Study

PAC02 - PACt-MD Intervention

PAC01 - PACt-MD Study time point(s):

* must provide value

[All time points]

Longitudinal

T0 (Baseline)

Short TX

Long TX

Please select the PAC01 - PACt-MD Study form(s) of interest:

* must provide value

[All forms]

Participant Summary

Tracking for Tableau

Consensus Conference Best Guess

Informed Consent

Adverse Events

Serious Adverse Events

Randomization

Participant Enrollment

Provisional Diagnosis

Visit

Demographics

Socio-Demographics

Hand Dominance Questionnaire

Prior Therapy

Psychotropic Medications

Nonpsychotropic Medications

Medical Conditions

Vital Signs with Weight & Height

Framingham Stroke Risk

Mini Mental Status Exam (MMSE)

Montreal Cognitive Assessment (MoCA)

Modified Hachinski Ischemic Scale (MHIS)

Driving Questionnaire

Cumulative Illness Rating Scale for Geriatrics (CIRS-G)

Montgomery-Asberg Depression Rating Scale (MADRS)

Structured Clinical Interview for DSM 5 Disorders (SCID)

Beck Scale for Suicidal Ideation (SSI)

Clinical Dementia Rating (CDR)

Wide Range Achievement Test (WRAT-4)

The Neuropsychiatric Inventory Questionnaire (NPI-Q)

Urine Drug Screen

EKG

MCI - Inclusion/Exclusion Criteria

Depression - MCI - Inclusion/Exclusion Criteria

Depression + MCI - Inclusion/Exclusion Criteria

Control - Inclusion/Exclusion Criteria

PASS-SR: Participant

PASS-SR: Informant

Everyday Cognition - Informant/Caregiver (ECog)

Everyday Cognition - Patient/Self Report (ECog)

Summary of NP Assessments

California Verbal Learning Test (CVLT-II)

Brief Visospatial Memory Test - Revised (BVMT-R)

Trail Making Test - A & B

Oral Trail Making Test A & B (OTMT)

Coding

Stroop

Benton Judgment of Line Orientation (JLO)

Paced Auditory Serial Addition Task (PASAT)

Performance Assessment of Self-Care Skills (PASS)

Clock Drawing Test

Letter Semantic Fluency

Boston Naming Test (BNT)

Continuous Performance Test - Identical Pairs (CPT-IP)

N-Back

EEG

EEG Tracking

Lumbar Puncture

Genotyping

Peripheral Biomarkers (BDNF)

MRI

MRI - PSMD Values Only

PET

Consensus

CC MRI Ratings

T0 Analyzed Genetics

T0 Analyzed CSF

T0 Analyzed SAA

T0 Analyzed MRI - Cortical Thickness

T0 Analyzed MRI - FA

T0 Analyzed MRI - MD

T0 Analyzed MRI - Subcortical Volume

T0 Analyzed PET

T0 Analyzed SASP

Medical History

Psychotropic Meds - Summary

Non-Psychotropic Meds - Summary

PAC02 - PACt-MD Intervention time point(s):

* must provide value

[All time points]

6 Months

12 Months

18 Months

24 Months

30 Months

36 Months

42 Months

48 Months

54 Months

60 Months

66 Months

72 Months

78 Months

84 Months

Please select the PAC02 - PACt-MD Intervention form(s) of interest:

* must provide value

[All forms]

Participant Summary

Randomization

First tDCS Session

tDCS Induction Phase

CR Induction Phase

Booster Scheduling

tDCS Consolidation Phase

Perceived Competency Scale

Intrinsic Motivation Inventory

Need for Cognition

Booster Summary

______ time point(s):

* must provide value

[All time points]

Longitudinal

Consent/Screening

Baseline

Intervention

1st Follow-up

2nd Follow-up

3rd Follow-up

Please select the ______ form(s) of interest:

* must provide value

[All forms]

Visit

Participant Status Log

Study Summary

Randomization

Informed Consent

Informed Consent Review

MCI Eligibility Check

Healthy Control Eligibility Check

Demographics

Sociodemographics

Medical History

Family Medical History

Medications List

CIRS-G - Cumulative Illness Rating Scale

MBI-C-Mild Behavioral Impairment Checklist

NIA-AA Checklist for MCI

MHIS - Modified Hachinski Ischemic Scale

Lab Results

TASS - Transcranial Magnetic Stimulation Adult Safety Screen

TASS - Transcranial Magnetic Stimulation Adult - Follow-Up

MRI Summary

HDQ - Hand Dominance Questionnaire

EHI - Edinburgh Handedness Inventory (10-item)

SCID-5 - Summary Sheet

MOCA - Montreal Cognitive Assessment

WRAT-5 - Wide Range Achievement Test - Word Reading

CDR - Clinical Dementia Rating

E-Cog - Everyday Cognition Patient

E-Cog - Everyday Cognition Caregiver

CVLT- California Verbal Learning Test

BVMT-R - Brief Visospatial Memory Test Revised

TMT - Trail Making Test A & B

WAIS-IV - Coding

JLO - Benton Judgment of Line Orientation

Fluency - Letter and Semantic Fluency

DKEFS - Delis-Kaplan Executive Function System - Color Word

BNT - Boston Naming Test

PASS - Performance Assessment of Self-care Skills

WAIS-IV - Letter Number Sequencing (LNS)

Spatial - Clock Drawing Test

PASAT - Paced Auditory Serial Addition Task

CPT-IP - Continuous Performance Test - Identical Pairs

Pre-EEG Questionnaire

N-Back Results

ESS - Epworth Sleepiness Scale

Pre-PAS SD-WISE - San Diego Wisdom Scale

PAS-EEG

Post-PAS SD-WISE - San Diego Wisdom Scale

PAS And PAS-C Baseline

PAS and PAS-C Intervention

Best Guess Questionnaire

EEG Tracking Log

Specimen Tracking Log

Adverse Event Log

Quality Assurance

______ time point(s):

* must provide value

[All time points]

TR1

TR2

TR3

TR4

TR5

TR6

TR7

TR8

TR9

TR10

TR11

TR12

Please select the ______ form(s) of interest:

* must provide value

[All forms]

Participant Status Log

Informed Consent

Eligibility Summary

Randomization

Neuropsychiatric Inventory Caregiver

Neuropsychiatric Inventory Participant

NPI-C - Neuropsychiatric Inventory Clinical Impression

CGI-S - Clinical Global Impression Scale Of Severity

CGI-C - Clinical Global Impression Of Change Assessment

CGI-C - Clinical Global Impression Of Change Treatment

CMAI - Cohen Mansfield Agitation Inventory

MoCA - Montreal Cognitive Assessment

SCIRS - Severe Cognitive Impairment Rating

FAST - Functional Assessment Staging of Alzheimer's Disease

AIMS - Abnormal Involuntary Movement Scale

BARS - Barnes Akathisia Rating Scale

SAS - Simpson Angus Scale

PAINAD - Pain Assessment In Advanced Dementia

ZBI - Zarit Burden Interview Scale

ADRQL - Alzheimers Disease Related Quality Of Life

Falls

Morse Fall Scale

CIRS-G - Cumulative Illness Rating Scale

Medical History Baseline

Medication Record

Lab Results

Medical History Exit

Participant Demographics

Caregiver Demographics

Pharmacological Intervention

ABC Checklist

PIECES Framework

ICP Score

Behavioural Interventions Care Plan

Behavioural Interventions Care Plan Summary

Summary Checklist

Cleanup Schedule

Event Reporting Log

COVID-19 Status Information

______ time point(s):

* must provide value

[All time points]

Baseline

tDCS

Please select the ______ form(s) of interest:

* must provide value

[All forms]

Informed Consent Log

Participant Status Log

Participant Demographics

Randomization

Medical History Baseline

Medication Log

SCID 5 Summary Sheet

DSM 5 Major Neurocognitive Disorder (Dementia) Checklist

Agitation in Cognitive Disorders Checklist

Eligibility Checklist AD Agitation Group

Eligibility Checklist AD Group

Eligibility Checklist HC Group

Neuropsychiatric Inventory Clinical Impression

Clinical Global Impression Scale Severity

Clinical Global Impression Of Change

Cohen Mansfield Agitation Inventory

Montreal Cognitive Assessment

Severe Cognitive Impairment Rating

Functional Assessment Staging Of Alzheimers Disease

Pain Assessment In Advanced Dementia

MRI Summary

TMS-EEG

tDCS Measurements

tDCS Treatment Log

Best Guess Questionnaire

Event Reporting Log

______ time point(s):

* must provide value

[All time points]

Please select the ______ form(s) of interest:

* must provide value

[All forms]

Participant Status Log

Informed Consent

Eligibility Criteria

Visit Form

Randomization

Demographics

Sociodemographics

Medical History

Medical Conditions

Medications List

Family Medical History

SCID5 Summary Sheet

PANSS - Positive and Negative Syndrome Scale

CDSS - Calgary Depression Scale for Schizophrenia

MoCA - Montreal Cognitive Assessment

SCIP - Screen For Cognitive Impairment In Psychiatry

TMT-A and TMT-B - Trail Making Test A and B

TOL - Tower Of London

ACB - Anticholinergic Burden Scale

PASS - Performance Assessment Of Self-Care Skills

FROP - Falls Risk For Older People

PPA- Psychological Profile Assessment

DIALOG Scale

Adverse Event Log

tDCS Measurements

tDCS Treatment Log

CR Log

Perceived Competency Scale

Intrinsic Motivation Inventory

Need For Cognition

______ time point(s):

* must provide value

[All time points]

Screening

Please select the ______ form(s) of interest:

* must provide value

[All forms]

Participant ID

Eligibility Checklist

Participant Status Log

Visit Checklist

MRI Summary

Demographics

MINI V7.0.2 Summary

WRAT-4 Word Reading Subtest (T0 only)

Medications List

Biomarkers

Vitals

Substance Use

Patient Health Questionnaire (PHQ-9)

Antidepressant Treatment History Form (ATHF)

Montgomeryasberg Depression Rating Scale (MADRS)

Beck Scale For Suicidal Ideation (SSI)

RBANS

Perceived Stress Scale (PSS)

WHODAS 12-item V2

UCLA Loneliness Scale V3

Fatigue Assessment Scale (FAS)

FRAIL scale

Everyday Cognition (ECog) 12-item

Generalized Anxiety Disorder Scale (GAD-7)

Cumulative Illness Rating Scale for Geriatrics (CIRS-G)

Montreal Cognitive Assessment (MoCA)

DKEFS Colour Word Interference

DKEFS Trail Making Test

DKEFS Verbal Fluency

CD-RISC-25

Participant Adverse Event Log

______ time point(s):

* must provide value

[All time points]

T1 - D1

T1 - D2

T1 - D3

T1 - D4

T1 - D5

T1 - D6

T1 - D7

T1 - D8

T1 - D9

T1 - D10

T1 - D11

T1 - D12

T1 - D13

T1 - D14

Please select the ______ form(s) of interest:

* must provide value

[All forms]

T0 Baseline Clinical

Informed Consent

Demographics

Sociodemographic Information

Prior Therapy

Concomitant Medications List

Medical History

Vital Signs With Weight & Height

Folstein Mini Mental Status Exam (MMSE)

Montreal Cognitive Assessment (MOCA)

Montgomery Asberg Depression Rating Scale (MADRS)

Screen for Cognitive Impairment in Psychiatry (SCIP)

Structured Clinical Interview for DSM-IV (SCID) Summary

Beck Scale of Suicidal Ideation (BSS)

Quality Of Life Scale (QOLS)

Zarit Burden Interview (ZBI)

Positive Aspects of Caregiving (PAC)

Diagnosis

MCI Inclusion/Exclusion Criteria

MDD-MCI Inclusion/Exclusion Criteria

MDD+MCI Inclusion/Exclusion Criteria

Adverse Events

Serious Adverse Event Report

Perceived Competency Scale Pcs

Intrinsic Motivation Inventory Imi

Need For Cognition (NFC)

Sheehan Disability Scale (SDS)

tDCS Measurements

Session Logs - Induction

Session Logs - Booster

Study Termination

______ time point(s):

* must provide value

[All time points]

Enrollment

Visit 1

Visit 2

Please select the ______ form(s) of interest:

* must provide value

[All forms]

Subject Identifying Information & Consent Details

Visit - Start

Demographics

History of Present Illness

Personal History

Languages Learned & Spoken

Lifestyle Habits

Current Medications

Allergies

History - Memory

History - Speech Language

History - Attention Concentration

History - Visuospatial

History - Executive Function

History - Psychiatric Symptoms

History - Sleep Disturbance

History - Personality & Behaviour

History - Gait & Balance

History - Bladder & Bowel Function

History - Activities of Daily Living

Past Medical History

Past Psychiatric History

Family Neurological History

Review of Systems

Mental Status Exam

MoCA Scores

MMSE Scores

TCT Scores

General Physical Exam

Mdsupdrs Motor Exam

Neurological Exam

Investigations Completed

Diagnosis

Active Contributing Factors

Opinion Recommendations

Visit - End

Please specify which COGBD study:

* must provide value

COGBD-O

COGBD-Y

COGBD-O time point(s):

* must provide value

[All time points]

Baseline

Year 1

Year 2

Year 4

Year 5

Year 6

Year 7

Year 8

Year 9

Year 10

Please select the COGBD-O form(s) of interest:

* must provide value

[All forms]

Participant Tracker

Baseline Demographics

Concomitant Medications List

SCID 4 Summary Sheet

Psychiatric History Baseline

Psychiatric History Followup

Drinking And Smoking Behaviour

Young Mania Rating Scale (YMRS)

Hamilton Depression Rating Scale (HDRS)

Cumulative Illness Rating Scale for Geriatrics (CIRSG)

Vital Signs

Blood Sample Log

Framingham Stroke Risk Profile (FSRP)

ECG

Lab Results

UCSD Performance-Based Skills Assessment (UPSA)

Functional Disability Inventory (FDI)

The Performance Assessment Of Selfcare (PASS)

Medication Management Ability Assessment (MMAA)

Reading The Mind In The Eyes (RMET)

Er40

The Awareness of Social Inference Test (TASIT)-Part 1 A

The Awareness of Social Inference Test (TASIT)-Part 2 A

The Awareness of Social Inference Test (TASIT)-Part 3 A

The Awareness of Social Inference Test (TASIT)-Part 1 B

The Awareness of Social Inference Test (TASIT)-Part 2 B

The Awareness of Social Inference Test (TASIT)-Part 3 B

TASIT SCORING (A&B)

Neuropsych Demographics

CANTAB

Continuous Performance Test (CPTIP)

MSCEIT Managing Emotions

Hand Dominance Questionnaire (HDQ)

Wechsler Test Of Adult Reading (WTAR)

Hopkins Verbal Learning Test (HVLT-R)

Trails A and B (TMT)

Trails C (TMT)

Clock Drawing Test

Simple Drawings

Bacs Symbol Coding (BACSSC)

Spatial Span (WMS-SS)

Letter Number Span (LNS)

NAB Mazes

Brief Visuospatial Memory Test (BVMT-R)

Stroop Neuropsychological Screening Test

Folstein Mini Mental Status Exam (MMSE)

Boston Naming Test (BNT)

The Executive Interview (EXIT)

Controlled Oral Word Association Test - Letters & Categories (COWAT)

Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)

California Verbal Learning Test (CVLT)

Logical Memory WMS III

Rey Osterrieth Complex Figure Test (RCFT)

Finger Tapping

Grooved Pegboard

Matrix Reasoning Test

Speed of Comprehension and Language Processing (SCOLP)

Letter Cancellation Test (LCT)

Block Design

Wisconsin Card Sorting Test (WCST)

WAIS III Digit Symbol

WAIS III Digit Span

COGBD-Y time point(s):

* must provide value

[All time points]

Baseline

Year 1

Year 2

Year 4

Please select the COGBD-Y form(s) of interest:

* must provide value

[All forms]

Participant Stats

Case Participant Assessment Checklist Baseline

Case Participant Assessment Checklist Follow Up

Informed Consent Checklist Baseline

Informed Consent Checklist Follow Up

Progress Notes

Baseline Demographics

Urine Drug Screen

Drinking And Smoking Behaviour

Concomitant Medications List

CIRS-G

YMRS Young Mania Rating Scale

HDRS Hamilton Depression Rating Scale

SCID 4 Summary Sheet

Psychiatric History Baseline

Psychiatric History Followup

UPSA

ER-40

RMET Reading The Mind In The Eyes

TASIT A: Part 1

TASIT A: Part 2

TASIT A: Part 3

TASIT B: Part 1

TASIT B: Part 2

TASIT B: Part 3

TASIT Scoring

Vital Signs

Lab Results

ECG

Framingham Stroke Risk Profile

Neuropsych Demographics

WTAR (Wechsler Test Of Adult Reading)

Hand Dominance Questionnaire

Folstein Mini Mental Status Exam

CPT-IP

Trails A and B

BACS Symbol Coding

HVLT-R

Spatial Span

Letter Number Span

NAB - Mazes

BVMT-R

MSCEIT Managing Emotions

Stroop Neuropsychological Screening Test

MRI Summary Sheet

Please specify the ______ for which you are requesting data:

* must provide value

______ time point(s):

* must provide value

[All time points]

Baseline

Follow-up (all)

Follow-up (specific time points)

Other

Please specify follow-up(s):

* must provide value

Please specify time point(s):

* must provide value

Please specify the ______ form(s) of interest:

* must provide value

Expand

Participant group:

* must provide value

Cases

Controls

Not Applicable

Individual item scores or summary scores?

* must provide value

Individual item scores & summary scores

Summary scores only

Not Applicable

reset

If applicable, please specify any additional inclusion criteria:

E.g., "Right handed"; "Age > 60"

Expand

If applicable, please specify any additional exclusion criteria:

E.g., "Exclude participants on drug X"

Expand

Additional comments:

Expand

Please note that this data request serves as a notification to Dewi Clark, Research Program Manager, Geriatric Mental Health Services.

Please allow for up to two weeks for data delivery.

Signature

* must provide value

Add signature

You have selected an option that triggers this survey to end right now.

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.