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Required format:

Translational Imaging Shared Resources (TISR) Research Imaging Request for Scan Time Application Form

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A A A

The purpose of this application is to request research scan time on one of the imaging modalities of the Translational Imaging Shared Resources (TISR) or clinical areas. This application is required by the institution in order to maintain consistent and complete documentation for all proposed studies that will use the scanning equipment. The Form also assists in reporting, scheduling, and projecting future needs and development.

If you have questions regarding the Form, please contact Tara Chavanne at tchavann@wakehealth.edu.

Thank you

Date of Request:

M-D-Y

Principal Investigator (PI) Name:

PI Department:

PI Phone Number:

PI Email Address:

Project Coordinator/Manager (PC/M) Name:

PC/M Phone Number:

PC/M Email Address:

Project Title:

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Estimated Start Date of the Project:

M-D-Y

Estimated End Date of the Project:

M-D-Y

WFBMC Chart of Account Number:

Is the PI a Cancer Center member?

Yes

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Number of Subjects

Sessions per Subject

Project Type:

Funded Grant

Submitted Grant

Planned Submission

Other

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Name of Funding Source:

Grant Number:

Please upload a copy of the Study Plan as submitted to the Funding Agency or the portion of the Study Plan that relates to imaging.

This is only for the purposes of ensuring that the imaging capabilities are present and will be kept highly confidential.

Upload file

Approximate Grant Due Date

M-D-Y

Please submit a copy of the research plan either as submitted for a grant application, or a draft of the research plan for a proposal that is being submitted. If preferred, you may submit the portion only related to imaging.

This is only for the purposes of ensuring that the imaging capabilities are present and will be kept highly confidential.

Upload file

Other, please specify:

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Do you know the scan time per session?

Yes

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Scan time per subject

If you do not know the scan time per session, please contact for guidance:

Research Scanners, please contact based on the modality:

MRI 3T or 7T, Clarkson CT contact Lena Moretz (63415)

Micro PET/CT, contact Kiran Sai (65630)

64 Slice PET/CT, contact Freda Crawford (63088)

Subject Type:

Human

Animal

Specimen

If the subject is human, are they:

Inpatient

Outpatient

Volunteer

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Is a clinical read by a radiologist needed?

Yes

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If a clinical read is needed, what type of read is required:

Full Clinical Read

Safety Check

Specialty/Other Read

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Does/Will this project have an IRB approval?

Yes, IRB is active or pending

No, IRB is not necessary

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IRB Number:

Animal Species:

Does/Will this project have an IACUC approval?

Yes, IACUC is active or pending

No, IACUC is not necessary

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IACUC Number:

Please attach documentation for obtaining the specimens. If bringing in specimens from an outside lab, a letter from Infection Control is also required.

Upload file

Are there any risk of contamination?

Yes

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If Yes, please attach a list of the potential risks and the steps to be taken to avoid them.

Upload file

Scanner Type:

* must provide value

Research Scanner

Hospital Clinical Scanner

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TIP Research Scanners:

* must provide value

3T MRI (Human or Large Animal)

CT (Siemens CT, Clarkson Campus, Animal only)

CT ONLY (GE 64-slice at Bowman Campus, MRI building, Human or Large Animal)

PET/CT (GE 64-slice, Human or Large Animal)

7T MRI (Small Animal only)

Micro PET/CT (Small Animal only)

MEG

HRpQCT/XtremeCT

MSOT Acuity (Human and Large animal)

Other

Please specify the other type of Research Scanner:

* must provide value

Hospital Clinical Scanners:

* must provide value

GE 1.5T MRI

Siemens 1.5T MRI

GE 3T MRI (Rad/Onc)

Siemens 3T MRI

GE 64-slice CT

GE 16-slice CT (CCC)

GE 64-slice PET/CT

GE 8-slice PET/CT (Rad/Onc)

MRI Unspecified

CT Unspecified

PET Unspecified

Other

Please specify the other type of Clinical Scanner:

* must provide value

Is a standard of care clinical report required?

* must provide value

Yes

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Are there any radiology measurements above the clinical standard of care?

* must provide value

Yes

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If yes, please describe:

* must provide value

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MRI Scanning:

Neuro

fMRI

Spectroscopy

Cardiac

Other

Please specify the other type of MRI Scanning:

Is Contrast required for MRI Scanning?

Yes

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If a Contrast is required, please select:

Study Provided Contrast

Translational Imaging will provide and bill for the Contrast

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CT Scanning:

4-D

Other

Please specify the other type of CT Scanning:

Is Contrast required for CT Scanning?

Yes

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If a Contrast is required, please select:

Study Provided Contrast

Translational Imaging will provide and bill for the Contrast

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If utilizing a PET Research Scanner, will the tracer be:

Made at the Wake Forest PET Facility

Supplied by the Investigator

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If the tracer will be supplied by the investigator, please describe the tracer and ordering process.

If a tracer is required, please select all that will be used during the study:

11C-Acetate

11C-Acetocetate

11C-Choline

11C-EKAP

11C-LY2975050

11C-Methionine

11C-MPC6827

11C-Nicotine

11C-PBR28

11C-Raclopride

64Cu-peptide/molecule

18F-FDG

18F-FDopa

18F-FES

18F-FLT

18F-FMISO

18F-FMT

18F-Florbetapir

18F-UCBH

89Zr-mAb/protein

Custom/Other

If a custom/other type of tracer is to be used, please describe:

Please provide information on the type of images that you would like. If you have a reference or references describing what you would like to do, please submit a copy of the references with this application. The more details that you provide, the easier it will be for the TISR to determine if the research scanners are capable of performing the studies that you are interested in. If you know the specific protocol that you are using, please attach your protocol to this application. The protocol should contain sufficient details to allow someone to reproduce your methods.

This is only for the purposes of ensuring that the imaging capabilities are present and will be kept highly confidential.

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Reference Upload

Upload file

Reference Upload #2, if applicable

Upload file

Protocol Upload

Upload file

An Approval Package consisting of the completed application, approval documentation, and a Letter of Support will be emailed to you upon approval.

Do you require a copy of the completed application PRIOR to receiving the Approval Package?

Yes

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Please provide additional comments or questions.

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How should data from scans be transferred to the PI?

TeraRecon Servers

FTP

Other

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If Other, please describe method:

Do you have access to TeraRecon?

Yes

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If you do not have access to TeraRecon, please complete the online application to request access:

TeraRecon Request Form

NOTE: Once you complete and submit the TeraRecon Request Form, please remember to return to this Online Application and submit this form.

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