Office Use Only
Routine Active
HREC/Billing No:_________
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 before submission to
the Ethics Committee. Before completing the form please read ‘Radiology & Nuclear Medicine Department
Guidelines: Services for Clinical Trials’ document. Please list all required tests and attach a 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: RadSafeRes@alfred.org.au
Victor Kalff
Email: v.kalff@alfred.org.au
Nuclear Medicine
Resource Centre Manager:
Radiation Oncology (William Buckland Radiotherapy Centre)
Resource Centre Manager:
Robin Smith
Email: robin.smith@wbrc.org.au
Section 1
Project Details:
Short Title:
Alfred HREC Number:
Department/Unit requesting:
Principal Investigator:
Coordinator:
(Request will not be processed without this number)
Extension:
Extension:
Email:
Expected commencement date:
Expected completion date:
Expected recruitment 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?
Estimated cost
(Radiation
Services Centre
to complete) †
* Y/N
†
Please note that these estimated costs are exclusive of GST. Please see note on Page 3 regarding applicability of GST.
*Please describe the routine patient care:
E.g. CT every 8 weeks for 48 weeks
Author: Research Coordinator
Approved by: Research Coordinator
Location: H:\Policy & Procedures\Research Unit
Control Number: F-RAD-264/1-01
Approval Date: June 2013
Page 1 of 3
Review Date: June 2016
RADIOLOGY, NUCLEAR MEDICINE & RADIATION ONCOLOGY
SERVICES
Section 2
Please complete all questions below
Do you require a study specific imaging protocol
(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)
If yes, do they need to be de-identified?
How many discs are required per patient visit?
What information is to be printed onto the disc?
Yes
No
Yes
Yes
No
No
Do you require more than a standard patient report? E.g. RECIST
If yes, please provide the name or send the reporting protocol
Yes
No
Do you require reporting by a specific consultant?
If yes, please provide name
Yes
No
Do you require a print out of the patient report?
If yes,
Name of requesting doctor
Copies to:
Yes
No
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
If yes, please specify
Yes
No
Will you require a ‘data dump’ of your imaging?
If yes, how frequently
Yes
No
Will you require QC imaging data to be sent to the sponsor ?
If yes, how frequently?
Yes
No
Will you require a NATA Accreditation Certificate
Yes
No
Will you require a signed copy of Head of Department CV
Yes
No
Author: Research Coordinator
Approved by: Research Coordinator
Location: H:\Policy & Procedures\Research Unit
Control Number: F-RAD-264/1-01
Approval Date: May 2015
Page 2 of 3
Review Date: June 2016
RADIOLOGY, NUCLEAR MEDICINE & RADIATION ONCOLOGY
SERVICES
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 Fees (if the ICAN/ECAN form is not completed your project will
not be reviewed):
Person responsible for account payment:
Establishment Fee payment
from Alfred Health Cost Centre (please complete ICAN on Page 4)
($150 for internal & funding agencies,
from Sponsor or external account (please note this will incur GST
$350 for externally sponsored trials)
charges) (please complete ECAN on Page 5)
Billing Details For Imaging Fees:
Imaging Fee payment
from Alfred Health Cost Centre (number to be debited:
)
from Sponsor or external account (please note this will incur GST
charges)
For imaging fee invoices direct to Sponsor provide contact details:
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: Research Coordinator
Approved by: Research Coordinator
Location: H:\Policy & Procedures\Research Unit
Control Number: F-RAD-264/1-01
Approval Date: May 2015
Page 3 of 3
Review Date: June 2016
ICAN NO _ _
BAYSIDE HEALTH
FINANCE USE ONLY
JOURNAL :
INTERNAL CHARGE ADVICE NOTE
PERIOD :
PLEASE COMPLETE ALL SHADED AREAS
BATCH/TRANS:
PLEASE CHARGE
(DEBIT)
COST CENTRE
DESCRIPTION
ALF
DELETE NOT APPLICABLE
ST.G
CG
PJ
C
C/CENTRE
5
FINANCE USE ONLY
FINANCE USE ONLY
TOTAL DEBIT
DESCRIPTION
OF CHARGES
0
0
0
0
0
0
DEFINITIVE
0 9 0 2
1
1
PLEASE REIMBURSE
(CREDIT)
COST CENTRE
DESCRIPTION
ALF
JOURNAL NO.:
DELETE NOT APPLICABLE
ST.G
CG
PJ
C
C/CENTRE
5
FINANCE USE ONLY
FINANCE USE ONLY
TOTAL CREDIT
0
0
0
0
0
0
DEFINITIVE
0 9 0 2
1
1
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 :
BOTH
GST EXTERNAL CHARGE ADVICE NOTE (ECAN)
(This is not an invoice)
No:
PLEASE CHARGE
Requesting Department
ADDRESS/ABN/UR No.:
Contact
Ext. No.
Cost Centre
ATTENTION OF
DATE
AMOUNT
DESCRIPTION
$
Radiology/Nuclear Medicine Services Establishment Fee
(HREC No. & Project Title:
)
GST
$
$
0 00
0 00
TOTAL VALUE
Grand Total
Including GST:
ACCOUNTS USE ONLY
(Please complete shaded areas. Resource
Centre Manager will submit ECAN to Finance.)
Authorised By
Debtor Code
Received By
Invoice No.
Date
Date
TOTAL
ACCOUNT TO BE CREDITED