Download Radiology Clinical Research Application Form Date of Request

Radiology Clinical Research Application Form
Date of Request:
Principal Investigator:
Study Title:
Protocol Number:
Sponsor
Budget #
( if applicable)
Study Contact:
Phone Number:
Email:
Radiology Lead Tech: Contact Information
Radiography
Amanda Chester
Doug Chilton
Hector Welsh--nights
Ronnie Lofton--weekends
Dionne Ross-evenings
Dale Edmunds
5201
7933
3746
3746
3746
3746
CT
Sherry Shirley
1111
MRI
Teresa Mills
3566
Interventional Radiology
Bryan Luckey
8220
Ultrasound
Laura Ricker
6669
Nuclear Medicine
Kelly Lovering
2867
Mammography
Kellie Bedebaugh
3319
Nursing
Lynda Roach
5401
To facilitate review of your proposal, for feasibility, approval, and estimated research
pricing by the Radiology Pricing and Review Committee, please complete the following:
1. Is any Radiology investigator already involved in the planning of your project? If “Yes”,
please give the Radiology investigator’s name. (The feasibility review process will determine if
radiologist involvement is required)
No
Yes
Name individual(s):
Most studies require interpretation by a clinical radiologist. Have you arranged for this?
No
Yes
(please specify)
Unsure
(please specify)
Does the radiologist have paid effort on the study? Is the radiologist a co-investigator?
No
Yes
(please specify)
2. What specific imaging is requested? Please enter “X” for each requested modality and
check the box for the location (s). Include any specific procedures require for each
image.
Angiography (Interventional Radiology)


Special Services:
Phantom required:
Yes
No
Phantom Frequency (please specify):
CT and or MRI (please specify)

Specific Anatomical areas of interest:


Specify type of contrast:
With Contrast
Without Contrast
Without and with Contrast
Specific CT equipment or functional required: (e.g. High definition cardiac, dual energy, perfusion, etc.):



Other specific techniques required (e.g. special reconstruction or post processing):
Phantom required:
Yes
No
Frequency (please specify):
Biopsy (please specify):
PET /CT

Specific Anatomical areas of interest:


Tracer(s):
Specify type of contrast for diagnostic CT:
With Contrast
Without Contrast
with Contrast
Other specific techniques required (e.g. dynamic, etc.):
Phantom required:
Yes
No
Phantom Frequency (please specify):


Nuclear Medicine





Specific Anatomical areas of interest:
Tracer (s):
Type and model of equipment:
Other specific techniques required:
Phantom required:
Yes
No
Phantom Frequency (please specify):
Ultrasound








Specific Anatomical areas of interest:
Procedure / exam description:
Ultrasound contrast required, please explain and specify type of contrast:
Doppler evaluation of vascular structures:
Specify type of contrast:
With Contrast
Other specific techniques required (e.g. 3D, image fusion, etc.):
Phantom required:
Yes
No
Phantom Frequency (please specify):
Biopsy (please specify):
Radiology Diagnostic





Specific Anatomical areas of interest:
Number of Views:
Specific requirements (e.g. dual energy, tomosynthesis, etc.):
Other specific techniques required:
Phantom required:
Yes
No
Phantom Frequency (please specify):
Without and
DEXA Bone Marrow




Specific Anatomical areas of interest:
Number of Views:
Other specific techniques required:
Phantom required:
Yes
No
Phantom Frequency (please specify):
3. Is the proposed procedure identical to a standard clinical protocol? If "No", please
indicate the specific sequencing. (Feasibility review process will determine if identical to a
standard protocol.)
Yes
No
(please specify)
4. Is the study supplying pharmaceuticals or devices for this proposal?
Yes
(please specify)
No
Other
(please specify)
5. Quality Control , Site Qualifications, or Image Data Management
Are there specific quality control procedures, site qualifications, or imaging
data management?
Yes
Please check either “Yes” or “No” and included description if marked “Yes”.
No
If “Yes”, write a narrative in the space below or as an attachment; answering the following:








Initial site evaluation form? Yes
No
Frequency
Describe the specific procedures required.
RECIST (Response Evaluation Criteria in Solid Tumors) measurements required? Yes
Who will perform this work?
Are there specific QC measures that must be done? Yes
No
Frequency
How often must the QC be repeated?
Does the QC need to be sent to another site? Yes
No
Frequency
a.
b.
c.
CPT Codes
CDM
No
Will the images be collected and sent for review to a central imaging facility? Yes
No
If imaging data collected, what transmission media will be used? (e.g. CD, Flash drive, secure
internet, etc.).
Have you arranged for transfer of the imaging data? (shipping, data transmission, etc… if needed)
Please specify.
Description
STORAGE MEDIA CD- $25.00
Tech Fee
Prof Fee
Radiology Approval: ___________________________________ Date: ______________________________
If you have any Radiology questions please contact Layne Mitchell, Business Manager, GRU Department of
Radiology BA 1410, Phone: 1-4586, [email protected] , or Yolanda Elam, RN, BSN Clinical Research
Nurse/Coordinator, 1-7040, [email protected] .