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FORM 2
Radiology Research Approval
Study ref:
Details of Imaging Services required
To be completed by Modality Principal Radiographer in discussion with the researcher.
Modality:
(CT, MRI, Nuclear Medicine, Xray, Ultrasound, DEXA, other).
Preferred make, model and specification of the equipment:
(e.g.Philips, Achieva, 1.5 Tesla)
Body Area(s) to be imaged:
(spine, brain, knee, heart, wrist, etc)
Please supply brief description of the imaging protocol: (attach copy on separate sheet as
appropriate)
Patients
Normal
controls
Healthy
Volunteers
In vitro,
specimen.
No of Subjects
No of Occasions examined
If multiple examinations, give interval(s)
between examinations
Do the appointment times need to be
coordinated with other tests, treatment or
clinics? Please specify in the protocol.
Which appointment times would NOT be
possible? (Daytime, evening, weekend, none)
Percentage of scan that is clinically indicated?
What is the likely recruitment rate into the
study?
(x new subjects per week/month etc)
No of acquisitions per examination
e.g. no if views, pre and post contrast, no of
MR pulse sequences/scan orientations.
Please provide complete list in protocol.
Estimated duration of each examination (in
minutes) (research + clinical components)
Contrast agent/radionulclide (specify)
Dose/activity
Drug delivery? (specify drug/dose)
Method of archive? (PACS, other- specify)
Estimated number of images per exam?
(give matrix size)
Film/Hardcopy? (No of sheets per exam)
Export of data required? (specify
media/network)
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O Other resources required
Patients
Normal
controls
Healthy
Volunteers
In vitro
specimen
Quantitative measurements required
(give details on protocol)
Post processing/ data analysis required
(specify)
Radiologist Report required.for research?
(in addition to clinical report and/or screening
for abnormality)
Discussed with radiologist (Y/N)?
(If yes please give name)
Patient booking/ reception services required
Imaging Protocol setup/development/testing
Will the subjects require sedation or general
anaesthetic? (please specify)
Medical Physics services required (Y/N)
If yes, please specify below:
Development/testing of imaging technique
QA
Scientific supervision of examinations
Data export/transfer
Data analysis
Phantom-only studies
No if sessions requested
Duration of session
Is a radiographer required?
Is Medical Physics support required?
Other resources required: (e.g. Purchase of new/additional hardware/software (please specify with
sources and costs where known).
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