Research Procedure Request Form

DEPARTMENT OF RADIOLOGY

Research Procedure Request Form

(Complete when planning/requesting radiological procedure for research studies)

Request Date: Quote Only (Please fill in 1-10a)Formal Request (Please fill in 1-10b)

1.Principal Investigator: Dept. Ph/fax: Pager:

2.Contact Person: Dept. Ph/fax: Pager:

3.Alternate Contact Person: Dept. Ph/fax: Pager:

4.Physician on Study: Dept. Ph/fax: Pager:

1. Name of the Radiology faculty member associated with this study:
2. Description of Research Study (please be brief):

1. Description of Requested Imaging Services (include CPT code) – describe Radiology involvement in the research study.

 Location of study to be performed: Main Hospital ACC Other:

 Preferred time of study: AM Weekend Time requirements of procedure:

PM

 Modality requested: CT Diagnostic Interventional Nuclear Vascular Lab

MRI Ultrasound Mammo DEXA

 Anticipated No. of Patients:

 Procedure(s) requested: CPT Code(s):

 # of exams per patient:

1. List any special requirements of Radiology services : none scheduling special reports special views new pulse

Explanation for item(s) selected: sequences

Image storage requested: Routine Procedure Film Videotape Disk DAT Special Formatting

Image transfer: yes no

10a. Type of Research requested: Funded study with report Funded blind study

NOTE: The Department of Radiology will no longer provide services for human research patients without a valid UCDHS

medical record number. It is the responsibility of the referring department to ensure that the patient is properly registered.

10b. List Funding Source(s) for Radiology services:

NIH Grant Private Sponsor Professional Society UCD/UCDMC Other (specify):

Dafis Funding: Chart: Account: Sub Acct: Object:

for radiology department use only

Radiology Research Vice Chairman:
______

Signature Date

BILLING INFORMATION: / Radiology Imaging Manager:
______

Signature Date

Comments:

Please return completed form to: Radiology Research Committee (RRC), Research Administrative Assistant, Imaging Center, UCDMC Phone: 734-3651 FAX: 734-0316

DEPARTMENT OF RADIOLOGY

IMPORTANT INFORMATION & REQUIRED DOCUMENTATION FOR

CLINICAL RESEARCH STUDIES

The Department of Radiology supports and encourages clinical research at UCDMC. Requests for clinical studies are reviewed by the Clinical Research Committee who give specific attention to patient safety, scheduling, procedure modification requests, any non-routine requirements of requested services, image storage and transfer requirements, and reimbursement of procedure charges. Investigators (PIs) should request procedure charge rates before submitting a new research/grant budget that includes Radiology services.

• The Department of Radiology highly recommends the PI work with a specific radiologist to discuss the research study. This will help determine procedures required and assist with more accurate cost estimates.

• Non-Routine Imaging Procedures: All research protocols/studies that involve non-routine imaging studies, e.g. studies involving modified acquisition, processing, analysis, display, and/or storage, must be reviewed and approved prior to study initiation.

• Procedure Fees/Cost Information: Information provided on The Department of Radiology Research Procedure Request Form will be used to determine pricing information and to develop a quote for research studies in the Department of Radiology. A quote is often requested by PIs/Clinical Coordinators in the planning stages of a study before the time that a contract is final. Unless the study is initiated immediately, the PI should be aware that pricing/costs might change.

Required Documents:

All investigators (PIs) planning to conduct research studies involving patients and/or volunteer subjects on imaging equipment in Radiology are required to file the following forms with the Department of Radiology:

Please use the check-off boxes below for items required by the Department of Radiology.

1. Completed Department of Radiology Research Procedure Request Form.

2. Copy of protocol.

3. Copy of Human Subjects Review Committee (aka IRB) approval.

IRB requirements include Radiation Use Committee (RUC) approval. Contact Lorraine Smith, . This committee is separate from the Dept of Radiology.

4. Copy(s) of consent form(s).

5. Copy of the approved UCDMC Bulk Account Application Form with the Dafis
account number.

Send items to:Radiology Research Committee (RRC)

c/o Research Administrative Assistant

Imaging Center, 4701 X St., UCDMC

Phone: 734-3651Fax: 734-0316

UNIVERSITY OF CALIFORNIA, DAVIS

BERKELEY  DAVIS  IRVINE  LOS ANGELES  RIVERSIDE  SAN DIEGO  SAN FRANCISCO SANTA BARBARA  SANTA CRUZ

DEPARTMENT OF RADIOLOGY J. ANTHONY SEIBERT, Ph.D.

UC DAVIS HEALTH SYSTEM PROFESSOR OF RADIOLOGY

RESEARCH IMAGING CENTER PHONE 916-734-0311

4701 X STREET FACSIMILE 916-734-0316

SACRAMENTO, CALIFORNIA 95817 EMAIL

(as of) May, 2002

To all principal investigators using Radiology imaging services for research:

The Department of Radiology will no longer accept research patients without a valid medical record number or proper registration through the department or research group requesting the study. The study coordinator (or designate) must fill out the pink radiology request form* (specifically used for reduced procedure charges for approved research studies) to ensure timely registration and scheduling through the Radiology Information System. For studies that are required to be anonymous, the patient name can be coded (after the information has been digitally archived) prior to delivery of digital images or film.

This change is necessitated by the digital archive database to avoid lost studies and for medico-legal protection if other inadvertent findings are noticed on the images during interpretation.

Should you have any questions regarding this policy change, please contact the Radiology Research director.

* Pink radiology request CalCode # 70000-436 (3/99)