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Integrated Medical Imaging VCH Corporate Office Integrated Medical Imaging Research Requirement Form 11th Floor-601 West Broadway Vancouver, BC V5Z 4C2 Tel 604:875:4355 Email: [email protected] Protocol #: Title of Study: Name of Principal Investigator: Research Department: Name of Study Coordinator: Phone: Email: Billing Contact Info: Name: Address: Phone Is this study MSP Billable? Yes No Do you require Phantom scan before site being approved for the study? Yes No Do you require a sample scan before site being approved for the study? Do you require Phantom scan? Yes No Yes No Do you require specific Imaging exam parameters for this study? Yes Email: Contact in Medical Imaging: Please provide Imaging manual No Please list Medical Imaging exam/study required under appropriate modality: CT: 1. 2. 3. MRI: 1. 2. 3. Ultrasound: 1. 2. 3. Nuclear Medicine : 1. 2. 3. Interventional: 1. 2. 3. GI/GU: 1. 2. 3. Start date of study: Anticipated end date of study (if known): Length of study: Which images require a diagnostic report? Total # of subjects/participants in the study: Which images require a copy on CD? rev: Nov 2012 CR General Radiology: 1. 2. 3. Number of follow-ups & frequency: Which images require anonamized or blinded? Medical Imaging Research Study Screening Checklist Integrated Medical Imaging VCH Corporate Office 11th Floor-601 West Broadway Vancouver, BC V5Z 4C2 Tel 604:875:4355 Email: [email protected] The following documents are required by Medical Imaging department before your research study request can be reviewed, and cost analysis can be provided. Please send completed forms to [email protected] VCH Request for Approval Application Research study protocol Medical Imaging manual Medical Imaging Research Requirement Form rev: Dec 2012 CR