Preclinical Mediso Pet Ct Scanner Access Form

PRECLINICAL MEDISO PET CT SCANNER ACCESS FORM

Located at Room LA44, AMREP, Prahran

PQMS3-MBI-FRM-P004-V1

Section 1Project Details

Project title ......

......

Project aims ......

......

Chief investigator ......

Proposed study start date/ completion date:......

Have you already used any MBI facilities for this project?

NOYES

If yes, what is the MBI Project Number of the existing project? ......

Finance details (person responsible for funding the studies)

Full name (person responsible for funding the studies)
School/Centre/Department
Faculty / Institute
University / Organisation
Email
Telephone

OR, if from Monash University, please provide a fund number and cost code for charges

Cost Code ...... Fund number ......

Finance officer in charge of this account ......

End date of research contract …………......

Project funding details: please specify the source and end date of grant or research contract funding for this project (e.g. NHMRC project grant, contract research)

......

Section 2Samples

Substances/tissues to be scanned ......

☐ Living ☐ Ex vivo ☐ Non biological

Approximate size of samples ......

Approximate number of samples ......

Desired resolution (if known): ......

Identify any hazards associated with your samples or associated experimental procedures:

Tick all that apply
Hazardous Substances/Dangerous Goods / Biological*
Explosive / Bacteria
Gas / Virus
Flammable/combustible / Human tissue/cells/fluid
Oxidiser or organic peroxide / Animal tissue/cells/fluid
Corrosive / Genetically modified organisms (GMOs)
Radioactive substance / Allergenic substances
Toxic Substance / Cytotoxin / Zoonotic (infectious) agents
Carcinogen / mutagen / teratogen / Hazardous proteins/peptides
Drug (e.g. anesthesia) / Mechanical/Equipment
Irritant/Harmful / Electrical equipment/tools
Sensitising agent / Non ionising radiation (e.g. laser)
Dusts/fibres
Nanoparticles / Other Hazards
Environmental pollutant / .

*Please indicate if biological samples are ‘fixed’ (i.e. infectivity is reduced). This may be via the use of aldehydes, alcohols, picrates, mercurials, oxidising agents etc.

If you have ticked any of the above, or have any other hazards which apply, please describe the hazard and what safety precautions you will implement along with the appropriate Risk assessments and SOP’s.

......

Section 3Modalities to be used

3.1 Does the project require use of PET?

NO Please proceed to 3.2

YES Please specify the radioisotope being used…………………………………………………...

This must be discussed with the Radiation Safety Officer before use.

3.2 Does the project require use of CT?

NO YES

Section 4 Animal ethics approval and holding

Does the project use live animals?

YES, and I have provided:

a Monash University Animal Ethics Committee approval number, and/or

an AMREP Animal Ethics Committee approval number, and

a copy of the AEC approval (and approval of any amendments), and

a copy of the original application (and any amendments) with this form.

Section 5Investigators

For every investigator who will be present during the scans, and the Chief Investigator, please provide the following information (copy and paste additional entries, if required)

5a) Investigators - ALL Monash Staff and Students Please Use This Section

External users, please provide investigator information on next page.

Investigator #1:

First name: ...... Surname: ...... Title: ......

Email:...... Phone: ......

Institution: ...... Department: ......

Mailing address: ......

……………………………………………………………………………………………………………………………

Staff /Student Number: ...... Authcate name: ......

Position:Staff (please specify e.g. research assistant, post doc)

Student (please specify e.g. honours, PhD)

This investigator has completed:

AMREP animal house induction training - completed on______

A copy of evidence of this training is attached

Monash University, Baker IDI or Burnet Institute (circle as appropriate) radiation training - completed on ______

A copy of evidence of this training is attached

Individual user radiation license (Department of Health) expires on ______

A copy of this license is attached

Radiation handling training for long half-life PET radioisotopes.

PET/CT operator training certified on ______

Radiation Badge (TLD) No. ______

Investigator #2:

First name: ...... Surname: ...... Title: ......

Email:...... Phone: ......

Institution: ...... Department: ......

Mailing address: ......

……………………………………………………………………………………………………………………………

Staff/Student Number: ...... Authcate name: ......

Position:Staff (please specify e.g. research assistant, post doc)

Student (please specify e.g. honours, PhD)

This investigator has completed:

AMREP animal house induction training - completed on______

A copy of evidence of this training is attached

Monash University, Baker IDI or Burnet Institute (circle as appropriate) radiation training - completed on ______

A copy of evidence of this training is attached

Individual user radiation license (Department of Health) expires on ______

A copy of this license is attached

Radiation handling training for long half-life PET radioisotopes.

PET/CT operator training certified on ______

Radiation Badge (TLD) No. ______

5b) Investigators - NON Monash staff and students please use this section

Monash users, please provide investigator information on previous page.

(copy and paste additional entries, if required)

Investigator #1:

First name: ...... Surname: ...... Title: ......

Email:...... Phone: ......

Institution: ...... Department: ......

Mailing address: ......

……………………………………………………………………………………………………………………………

Position:Staff (please specify e.g. research assistant, post doc)

Student (please specify e.g. honours, PhD)

This investigator has completed:

AMREP animal house induction training - completed on______

A copy of evidence of this training is attached

AMREP radiation training - completed on ______

A copy of evidence of this training is attached

Individual user radiation license (Department of Health) expires on ______

A copy of this license is attached

Radiation handling training for long half-life PET radioisotopes.

PET/CT operator training on ______

Radiation Badge (TLD) No. ______

Section 6 Data collection and storage

Raw imaging data collected from each scanner is typically archived on a central Monash University server system called “MyTardis”. This server includes a web-based access controlled system to view and download your files and is free for all MBI users.

Who has access to my data? Only users specified on this form will have access to your specific data folders. Note: All pre-clinical data generated at MBI on MyTardis is accessible by the head of pre-clinical imaging, the director and the facilities manager at MBI and certain Monash IT staff members.

Do you wish to use MyTardis? ☐NO ☐YES

If YES please specify names and email of the people you wish to access the data via the web server.

MBI Project number access: Access to all your research group’s imaging data.

Name:...... Email: ...... Authcate: .....

User folder access: Access to only the specific user’s imaging data (not required if listed above)

Name:...... Email: ...... Authcate: .....

If NO: Contact the head of pre-clinical imaging directly or via email to ().

Section 7Summary of Terms and Conditions

Full details of the terms of conditions of use for the Mediso PET/CT are at https://platforms.monash.edu/MBI > Forms and Policies > MBI Policies (policy number 1). By signing this agreement the chief investigator agrees to these terms in full.

Key user responsibilities are listed below:

1. Acknowledge MBI for provision of the Mediso PET/CT in your research outputs, including in the acknowledgements section of scientific publications

2. Provide a copy to MBI of scientific publications arising from use of the Mediso PET/CT.

3. Pay the hourly costs associated with use of the Mediso PET/CT as detailed in this application and found by clicking here or at https://platforms.monash.edu/MBI > Facilities > Prices.

4. Chief investigator will ensure staff and students working on the project will follow all MBI and AMREP occupational health and safety and radiation requirements on site.

Section 8Chief Investigator Agreement

As chief investigator of this project I agree to abide by the terms and conditions as outlined at https://platforms.monash.edu/MBI > Forms and Policies > MBI Policies (policy number 1). and approve data access for researchers listed on this form.

Signed:...... Date: ______/ ______/ ______

Name: ......

Please return this completed form via email to ()

Preclinical Mediso PET CT Scanner Access FormPQMS3-MBI-FRM-P004-V1Page 1 of 5

Date of issue: 08/06/2016

Printed copies of this document are uncontrolled copies. For current versions refer https://confluence-vre.its.monash.edu.au/