Download Image Upload to Research PACS Intake Form

BWHResearchImagingCore(BRIC)ImageUploadto
ResearchPACSIntakeForm
Date Title of Project Project Nickname (to be given by BRIC) Name of Principal Investigator Co‐Investigators User ID: User ID: User ID: User ID: Other Authorized Researchers User ID: User ID: User ID: User ID: Dept. Admin/Finance Mgr. to be copied Name: on invoices IRB Protocol Number IRB Expiration Date Partners PeopleSoft Account Number Funding Source Number of Exams to be Imported Format of Images to be Imported Study Start Date Study End Date User ID: Email: If images are currently in the BWH clinical PACS, please provide the Date of the Exam and MRN numbers for each of the studies to be uploaded. Date of Exam MRN Notes/Comments