Center for Advanced Computed Tomography Imaging Services CACTIS

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Nov 15, 2013 (3 years and 6 months ago)

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Center for Advanced Computed Tomography Imaging Services
CACTIS



Specimen/Phantom CT Research
Application Form




Version 2, 2013
-
Jan
-
16



D
ate
:








New Application
:








Renewal
:








Modification
:














Protocol Title
:







Brief description of protocol
:







Brief pro
gress report for renewal
:







Brief description of modification request
:







Principal Investigator
:







Address:






Office number:






Pager number:







Email address:







Study Contact
:







Address:






Office number:






Pager number:







Email address:








Name of Radiology Faculty Member
*

invol
ved with this research
:






Contact information:







*must be listed as Co
-
Investigator or Sub
-
Investigator


1) Is this study funded?

YES


NO


FUNDING SOURCE:

NIH/NCI Grant:







Grant number:






Sponsor:






OTHER (please provide explanation):









BEN

ACCOUNT**:






**
Account number must be listed otherwise application will

not be accepted.



Business Administrator Contact:







Email:








Phone:








PI Signature
: ________________________________________________

(
by signing the PI acknowledges
that CACTIS will ded
uct the cost of the CT exams from the above account.
A copy of this form with an
original signature must be on file prior to full approval)



2) Has this study been reviewed by the IRB?

YES

NO

If yes, please include a

current copy of the IRB approval letter and dated consent form to be used in
conjunction with this research.


Center for Advanced Computed Tomography Imaging Services
CACTIS



Specimen/Phantom CT Research
Application Form






3) CT Research Time

How much scanner time will be necessary per session?






How many sessions in all
?







4) Type of Research


Specimen


YES


NO


Describe type:








Phantom

YES


NO


Describe type:







Other:


YES


NO


Describe type:








THIS SECTION TO BE FILLED OUT BY RESEARCH COMMITTEE


DATE OF REVIEW: __________________



DATE OF RE
-
REVIEW: _______________

APPROVED: _______________
__________




RE
-
APPROVED: _____________________

NUMBER OF APPROVED SESSIONS: ___________________

ACCOUNT CODE: ____________________________________

EXPIRATION DATE: ________________________

RECOMMENDATIONS: ________________________________________________
_

_______________________________________________________________________


Center for Advanced Computed Tomography Imaging Services
CACTIS



Specimen/Phantom CT Research
Application Form






PROTOCOL PAGE



Custom Protocol


Please Describe:







Custom Protocol Table


Please provide parameters in the table below.


kV







mAs







Slice collimation







Slice width








Feed/Rot.








Rot. Time








Recon. Kernel








Increment








Direction








Coverage








Oral contrast








IV contrast








IV contrast
injection rate








Scanning Delay










NOTE
: Post
-
processing, including sagittal or coronal mult
iplanar reformatting, etc, can be done automatically on
the CT console. Any additional post
-
processing will be charged a separate rate. This rate must be negotiated
and signed off on prior to the study start date.


Additional reconstructions?

YES


NO


Please provide explanation:







Post Processing:


YES


NO

Coronal MPR:






Sagittal MPR:













_____________________________
________



________________________

Principle Investigator Signature




Date


Center for Advanced Computed Tomography Imaging Services
CACTIS



Specimen/Phantom CT Research
Application Form