Research Procedure Request form
Radiological Services Request
Requesting Department Information
Department Name:
Principal PI Name:
Additional information:
Contact Person (CRC, etc.):
Contact Person Phone #:
Project Information
Project start date:
Study Title (per Protocol):
Project end date:
IRB#
Project name (assigned):
Study sponsor:
DaFIS account number:
Study MRN# (Bridge/EMR):
Technical Procedures Being Requested (radiological exams, etc. – please describe)
1)
2)
3)
4)
5)
Special notes/requests:
Imaging location:
Main Hospital
Imaging time preferences/needs:
Modality/cost center:
Ambulatory Care Ctr
AM
PM
Weekend
CT
Diagnostic
Nuclear
PET
Ultrasound
Mammo
DEXA
Who supplies the tracer (PET):
UCDHS
Who supplies the contrast (CT/MRI):
Sponsor
Imaging Research Ctr
Other
Vascular Lab MRI
Interventional Radiology
Not Applicable
Not applicable
UCDHS
Professional services – do you need the images read by a radiologist?
Sponsor
Yes
No
Data/Imaging Transfer Information
Image storage requested:
Standard (Stentor)
Is an image transfer being requested?
Yes
Disc
Videotape
Special Formatting
No (Transfer requests are completed through the Film Library)
For Radiology Internal Use Only
Radiology Research Vice Chairman:
Radiology Modality Reviewer:
Signature
Signature
Date
Date
Internally assigned project name:
Please submit research protocol, imaging acquisition guidelines, IRB approval and this form
to:
research-radiology-som@ucdavis.edu