Radiology Clinical Research Application Form

UW Medicine Radiology Clinical Research Application Form RV 3/3/16 (final)

Radiology Clinical Research Application Form
HMC / SCCA / UWMC
Purpose of This Form:
The Radiology Clinical Research Application Form is required for the use ofclinical research exams (with imaging scanners/devices) and procedures at University of Washington Medical Center (UWMC), Harborview (HMC), Roosevelt and Seattle Cancer Center Alliance (SCCA) in the Imaging Department.
If the proposed research protocol does not use clinical imaging scanners or procedures in Imaging Department(s) (UWMC, HMC, or SCCA) or is a non-human study;DO NOT complete this form. Instead, contact the manager of the dedicated research imaging center listed below for their review and pricing information.
BMIC (Dedicated Research 3T MRI)
BioMedical Imaging Center
Chun Yuan, Director
Radiology, South Lake Union
850 Republican Street
Seattle, WA 98109
Phone number: 206-616-1697
Email: / DISC(Dedicated Research 3T MRI)
Diagnostic Imaging Science Center
Liza Young
Radiology, UW Health Sciences
Box 357115
Phone number: 206-685-0457
Email: / PET/CT (Dedicated Research PET/CT)
Barbara Lewellen
Radiology, Harborview Medical Center
Phone number: 206-598-5523

Email:

Radiology Clinical Research Contacts:
CONTACT / PHONE / EMAIL
Radiology RADRRR Application Process (UWMC, Roosevelt, HMC) / 206-543-5716 /
SCCA Research Implementation Office (RIO) / 206-288-7116 /
CRBB RRR Budgets
/ 206-543-7774 /
RECIST Reads/OncoRad/TIMC
Pricing Listing and Billing Procedure for Tumor Measurement / 206-598-9322 /
UWMC Radiation Safety Compliance Office

/ 206-685-5313 or 206-543-0463 /

UW Medicine

Radiology clinical research application form

HMC/SCCA/UWMC
to faciliate and review yourproposal for feasibility, approval, and estimated research pricing by the Radiololgy RESEARCH Review Committee, please complete the following questionnaire:
Request Date:
Principal Investigator Name:
Co-Principal Investigator Name (if applicable):
Department:
Protocol Number or Study Title:
Grant/Contract Number (if applicable):
Budget number and/or eGC1# (if available):
Sponsor: / Flow-through: No Yes / If yes, prime sponsor:
Study Contact:
Email:
Phone:
Please place “X” in one of the following boxes
Pricing for CRBB RRR Account (Clinical Research and Billing)
Preliminary price estimate only (These prices cannot be used to obtain the RRR Account from CRBB)

Clinical Resources Location: (Please enter “X” in the box next to all proposed sites)

HMC
SCCA
UWMC
ROOSEVELT

Is any Radiology investigator already involved in the planning of your project? If “Yes”, please give the Radiology investigator’s name. (The feasibility review process will determine if radiologist involvement is required.

NO
YES / Name Individual(s):
Most studies require interpretation by a clinical radiologist. Have you arranged for this?
NO
YES / Please specify:
Does the radiologist have paid effort on the study?
NO
YES / Please specify:
Is the radiologist a co-investigator?
NO
YES / Please specify:

What specific imaging is requested? Please enter “X” for each requested modality and check the box for the location(s). Include any specific procedures required for each image.

Biopsy
Location: UWMC SCCA HMC
Specific Anatomical areas of interest (please select all that apply):
Kidney/Renal / CT / US / CT/US
Liver/Hepatic / CT / US / CT/US
Lung/Mediastina (chest) / CT / US / CT/US
Lymph Node / CT / US / CT/US
Bone: Deep (hip or femur/thigh bone) / CT / US / CT/US
Bone: Superficial (ilium or sternum) / CT / US / CT/US
Muscle/soft tissue / CT / US / CT/US
Ovary / CT / US / CT/US
Pancreas / CT / US / CT/US
Prostate / CT / US / CT/US
Other (Please Specify): / CT / US / CT/US
Other techniques required (e.g. special reconstruction or post processing):
Angiography (Interventional Imaging)
Location:UWMC SCCA HMC
Specific Anatomical areas of interest (please specify):
Procedure Descriptions:
Other (please specify):
Other techniques required (e.g. Functional anatomical, diffusion weighted, angiography, unique for qualifications, different sequences or dynamic, etc.):
CT
Location: UWMC SCCA HMC
Specific Anatomical areas of interest (please select all apply):
WO=without contrast; W=with contrast; WOW= without and with contrast
Head
Neck / WO / W / WOW
Cardiac / WO / W / WOW
Chest / WO / W / WOW
Abdominal / WO / W / WOW
Pelvis / WO / W / WOW
Lumbar Spine / WO / W / WOW
Cervical Spine / WO / W / WOW
Thoracic Spine / WO / W / WOW
Upper Extremity / WO / W / WOW
Lower Extremity / WO / W / WOW
Other (Please Specify): / WO / W / WOW
Other techniques required (e.g. special reconstruction or post processing): / WO / W / WOW
Specific CT equipment or functions required: (e.g. High definition cardiac, dual energy, perfusion, etc.):
Phantom required: No Yes Frequency (please specify):
MRI
Location: UWMC SCCA HMC
Specific Anatomical areas of interest (please select all apply):
WO=without contrast; W=with contrast; WOW= without and with contrast
Brain / WO / W / WOW
Neck / WO / W / WOW
Cardiac / WO / W / WOW
Chest / WO / W / WOW
Abdominal / WO / W / WOW
Pelvis / WO / W / WOW
Lumbar Spine / WO / W / WOW
Cervical Spine / WO / W / WOW
Thoracic Spine / WO / W / WOW
Upper Extremity / WO / W / WOW
Lower Extremity / WO / W / WOW
Bone Marrow / WO / W / WOW
Other (Please Specify): / WO / W / WOW
Are there specific MRI techniques, sequences, or functional parameters required beyond a standard clinical MRI (e.g. 1.5T, 3T, diffusion weighted, dynamic, cardiac specifics, or angiography)?
Other techniques required (e.g. special reconstruction or post processing):
Other specific technique required (e.g. Functional, anatomical, diffusion weighted, angiography, unique for qualifications, different sequences or dynamic, etc.):
Phantom required: No Yes Frequency (please specify):
PET/CT
Location: UWMC SCCA HMC
Please Note: For HMC PET-CT, if imaging procedures are paid by research funding/account, STOP – DO NOT completethis form.Instead, please contact the Director of Nuclear Medicine, Radiology, Dr.David Lewis, at
Specific Anatomical areas of interest (please specify; whole body, limited, bone, etc.):
Type of Tracer (S):
Other specific techniques required (e.g. dynamic, etc.):
Phantom required: No Yes Frequency (please specify):
Nuclear Medicine
Location: UWMC SCCA HMC
Specific Anatomical areas of interest (please select all apply):
Whole body bone
Tumor
MUGA
SPECT/CT
Type of Tracer (S):
Other (please specify anatomical area of SPECT/CT):
Other techniques required (please specify if limited):
Ultrasound
Location: UWMC ROOSEVELT HMC SCCA
Specific Anatomical areas of interest (please select all apply):
Liver
OB (which trimester):
Duplex/Doppler: Vascular Non-vascular Bilateral Unilateral
Abdomen Kidney Extremities (upper/lower):
Other (please specify):
Procedure/exam description:
Phantom required: No Yes Frequency (please specify):
Radiologic Diagnostic
Location: UWMC ROOSEVELT HMC SCCA
Specific Anatomical areas of interest (please specify):
Number of Views:
Specific requirements (e.g. dual energy, tomosynthesis, etc.):
Other techniques required (please specify):
DXA or DEXA Diagnostic (Dual energy X-Ray absorptiometry)
Location: UWMC ROOSEVELT HMC SCCA
Axial (Hips/Spine)
Peripheral (append, wrist)
Vertebral fracture assessment
Body composition

Number of proposed subjects/years of study/scan per subject.

Number of Subjects:
Number of Years:
Number of Scans per Subject:

Is the proposed procedure identical to a standard clinical protocol? If "No", please indicate the specific sequencing. (Feasibility review process will determine if identical to a standard protocol.)

NO
YES / Please specify:

Is the study supplying pharmaceuticals or devices for this proposal?

NO
YES / Please specify:

Quality Control, Site Qualifications, or Image Data Management.

Initial site evaluation form? No Yes Frequency
Describe the specific procedures required.
Who will perform this work?
Are there specific QC measures that must be done? No Yes Frequency
How often must the QC be repeated?
Does the QC need to be sent to another site? No Yes Frequency
Will the images be collected and sent for review to a central imaging facility? No Yes
If imaging data collected, what transmission media will be used? (e.g., CD, Flash drive, secure internet, etc.).
Have you arranged for transfer of the imaging data? (Shipping, data transmission, etc.). Please specify:
Are measurements of tumors, such as RECIST reads, required? Yes No (If yes, please contact Diane Guay at 206-598-9322 or for pricing and billing procedure)

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