RADIOLOGY, NUCLEAR MEDICINE & RADIATION ONCOLOGY SERVICES

Any projects involving radiation oncology, nuclear medicine or radiology services must have a declaration from the relevant Resource Centre Manager. The form below is to be completed and signed by the PI beforeit is emailed to the Resource Centre Manager. Before completing the form please read ‘Radiology & Nuclear Medicine Department Guidelines: Services for Clinical Trials’ document. Please list all required tests and attachatrial summary protocol and imaging protocol.

DECLARATION FROM RESOURCE CENTRE MANAGER

Resource Service you require (check all that apply):

Radiology & MRI

Resource Centre Manager: Helen Kavnoudias Email:

Nuclear Medicine

Resource Centre Manager: Martin Cherk Email:

Radiation Oncology (William Buckland Radiotherapy Centre)

Resource Centre Manager: Robin Smith Email:

Section 1

Project Details:

Short Title:

Alfred HREC Number:(Request will not be processed without this number)

Department/Unit requesting:

Principal Investigator:Extension:

Coordinator: Extension:

Email:

Expected commencement date: Expected recruitment completion date:

Expected completion date:

Submission date for The Alfred HREC approval?

Resources Required:

Imaging (e.g. CT abdomen)
If requesting CT please specify with or without contrast / No.
of Patients / Imaging schedule
(e.g. baseline, 3month, annually) / Is the test additional to routine patient care?
* Y/N / Estimated cost
(Radiation Services Centre to complete) †

† Please note that these estimated costs are exclusive of GST. Please seenote on Page 3 regarding applicability of GST.

*Please describe the routine patient care:

E.g. CT every 8 weeks for 48 weeks

Section 2

Please complete all questions below

Do you require a study specific imaging protocolYes No

(see guidelines for explanation, commercial sponsors usually provide an
imaging protocol separate to the main study protocol)

Will you require a CD of the images (DVD available on request from Nuc Med) Yes No

If yes, do they need to be de-identified?Yes No

How many discs are required per patient visit?

What information is to be printed onto the disc?

Do you require more than a standard patient report? E.g. RECISTYes No

If yes, please provide the name or send the reporting protocol

Do you require reporting by a specific consultant?Yes No

If yes, please provide name

Do you require a print out of the patient report?Yes No

If yes, Name of requesting doctor

Copies to:

Do any study specific forms need to be completed by radiation services?Yes No

If yes, please provide a copy of the forms

(NB: radiation services staff will not complete CRFs or organise shipment of digitised data to sponsor)

For CT imaging do you require 3D reconstruction of your images? Yes No N/A

For PET imaging do you require SUV measurements? Yes No N/A

Will you require any other image measurements Yes No

If yes, please specify

Will you require a ‘data dump’ of your imaging? Yes No

If yes, how frequently

Will you require QC imaging data to be sent to the sponsor?Yes No

If yes, how frequently?

Will you require a Accreditation CertificateYes No

Will you require a signed copy of Head of Department CVYes No

Section 3

Funding, Fees & Account Details:

For explanation of fee structure please see ‘Radiology & Nuclear Medicine Department Guidelines: Services for Clinical Trials’

External Sponsor:Yes No If yes, Name of Sponsor:

Research Funding Agency: NHMRC Other (specify):

Internal, not sponsored:Yes No

Billing Details For Establishment Fee:

Establishment Fee payment: from Alfred Health Cost Centre No:
(please complete ICAN on Page 4)

from Sponsor or external account (incurs10% GSTcharge)
(please complete ECAN on Page 5)

Billing Details For Imaging Fees: NB: For Alfred Depts imaging will only be charged to an Alfred Cost Centre; imaging invoices will not be sent directly to study sponsors.

Imaging Fee payment from Alfred Health Cost Centre No.
External account (incurs 10% GST charge)
For Establishment and/or Imaging Fee invoices direct to Sponsor provide contact details

Company:

Attention to:

Address:

The ICAN form on page 4 must be completed and signed by the PI for your project to be reviewed

Section 4

To be completed by the Resource Centre Manager:

Short Title of Project:

Radiation Services:

Signature:...... ……...... Date:…………….

Name: …………………………………………………………………………………Ext:………….…..

Undertaking by Chief Investigator of the trial:

  • Agrees to look after all funding arrangements between The Alfred and the sponsoring body;
  • Agrees to ensure that adequate funds are available and that payments of invoices are from an Alfred hospital cost centre or special purpose fund and will cover all the agreed costs within the time frames set out by the servicing unit;
  • Agrees to any conditions outlined by the supporting department;
  • Knows that default of payment may prejudice approval of future trials;
  • Will contact the supporting service at commencement of the trial;
  • Agrees if the trial has not commenced within 6 months of the costing date, will re-confirm prices with the supporting department;
  • Agrees to notify the relevant support services upon completion of the trial.

Signature of Chief Investigator..…...... Date:......

Name:…………………………………………………………………………………………………………………………………

Author: Helen Kavnoudias / Control Number: F-RAD-264/2-00 / Page 1 of 3
Approved by: Helen Kavnoudias / Approval Date: June 2016 / Review Date: Aug 2018
Location: H:\Policy & Procedures\Research Unit

ICAN NO _ _
BAYSIDE HEALTH
INTERNAL CHARGE ADVICE NOTE
PLEASE COMPLETE ALLSHADEDAREAS / FINANCE USE ONLY
JOURNAL : / BOTH
PERIOD :
BATCH/TRANS:
JOURNAL NO.:
PLEASE CHARGE
(DEBIT) / DELETE NOT APPLICABLE / PLEASE REIMBURSE
(CREDIT) / DELETE NOT APPLICABLE
ALF / CG / PJ / ST.G / ALF / CG / PJ / ST.G
COST CENTRE / COST CENTRE
DESCRIPTION C C/CENTRE DEFINITIVE / DESCRIPTION C C/CENTRE DEFINITIVE
5 / 0 / 9 / 0 / 2 / 5 / 0 / 9 / 0 / 2
FINANCE USE ONLY / 0 / 0 / 0 / 1 / FINANCE USE ONLY / 0 / 0 / 0 / 1
FINANCE USE ONLY / 0 / 0 / 0 / 1 / FINANCE USE ONLY / 0 / 0 / 0 / 1
TOTAL DEBIT / TOTAL CREDIT
DESCRIPTION
OF CHARGES / Radiology/Nuclear Medicine Services Establishment Fee: (insert HREC number and project title)
(Resource Centre Manager will submit ICAN to Finance)
CERTIFICATION / DEPARTMENT(S) CHARGED AUTHORISATION / DEPARTMENT(S) REIMBURSED AUTHORISATION
SIGNATURE : / SIGNATURE :
PRINT NAME : / PRINT NAME :
COST CENTRE : / COST CENTRE :
DATE : / DATE :

GST EXTERNAL CHARGE ADVICE NOTE (ECAN)

(This is not an invoice)

PLEASE CHARGE / Requesting Department
ADDRESS/ABN/UR No.: / Contact
Ext. No. / Cost Centre
ATTENTION OF
DATE / DESCRIPTION / AMOUNT
$ / GST
$ / TOTAL
$ / ACCOUNT TO BE CREDITED
Radiology/Nuclear Medicine Services Establishment Fee
(HREC No. & Project Title: ) / 0 / 00
TOTAL VALUE / 0 / 00
Grand Total
Including GST:
Authorised By
Received By
Date