Principal Investigator:

Telephone:

E-mail:

Pager:

Department of Origin: ______________________________________

Research Coordinator:

Telephone:

E-mail:

Pager:

Department Administrator:

Telephone:

E-mail:

Pager:

Have you already consulted with a Radiologist or Physicist (other faculty),etc in the Radiology Dept?      Yes    No

Name_______________________________________

Do you have a specific radiologist or Physicist (other faculty) that you wish to work with?   Yes   No

Name_______________________________________

Research Sponsor:

Account Fund:

Budget Period

Start:

End

IRB #              

IRB Approval Date:

Pending:  Yes   No

Brief Study Description:

What  imaging studies are requested (modality, region of interest, sequences,projections,contrast?, etc )

Analyses requested (please provide details):

Clinical interpretation  requested (Yes____/No____).

If yes, standard interpretation of results? (Yes___/_No___

And/ or specialized analyses (diameters, volumes, other quantitative analyses).

Please specify.

DATE ESTIMATED TO BEGIN SCANNING (MONTH/YEAR):___________________________________Total

No. Patients Projected: _______

Total Number Of Imaging Studies Per Patient: ______

Frequency of studies per patient(once, weekly, monthly, etc)__________

Total Number Of Imaging Studies  ________

Additional comments:

Procedures to be reimbursed by medical insurance? ______

Please Answer The Following Questions:

YES

NO

Are you requesting assistance from Radiology faculty or staff in project design/development, ongoing collaboration, and/or imaging data analysis as a co-investigator..

Are there specific quality assurance/quality control measures? If, so, please explain below.

Are there study-specific tracking forms that must be completed and maintained by the radiologic technologists, including Data Transmittal Forms, FTP of data,etc? If so, this will require coordination with chief technologist? Please specify below: