CLINICAL TRIAL REQUEST FOR IMAGING SERVICES
**All clinical trial imaging exams, procedures & reports will be transmitted to eRecord,
MyChart & RHIO.
Date of Request:
Name of Trial:
Billing Contact:
Principal Investigator:
Study Coordinator:
Trial Sponsor:
NIH
Estimated # Subjects:
Industry
Phone/Ext #:
Company:
Other:
Estimated Start Date:
Estimated End Date:
SC:
Ph./Ext #:
Box #:
Box #:
FAO/Grant #:
Frequency of Exams:
*REQUESTED EXAMS and/or PROCEDURES – Billable to the Study Ledger
*SOC image acquisition & dictation will be followed unless otherwise requested*
Research Indication for Exam(s) and/or Procedure(s):
Plain Film X-ray Body Part(s):
Ultrasound Organ/Body Part(s):
PET CT
Limited
Skull to Mid-thigh
Whole Body
MRI (√ all that apply)
Contrast:
Without
Without & With
Magnet Strength:
3T
1.5T
1.0T
MR Spectroscopy
MR Angiogram
fMRI (brain)
MR Perfusion DCE
MR Perfusion ASL MR DTI
CT Scan (√ all that apply)
Contrast:
With
Without
CT Angiogram
CT Perfusion
View(s):
With Doppler
Without Doppler
Other:
BODY PART(S) (√ all that apply)
Head/Brain
Neck
Chest
Abdomen
Pelvis
Musculoskeletal:
Spine:
Cervical
Thoracic
Lumbar
Sacrum
Organ/System:
Esophagus
Stomach
Liver
Kidney
Brain
Other:
Without & With
CT Myelogram
Lymphatics:
Vascular System:
Venous
Arterial
Vessels:
Lumbar Puncture CSF with Fluoroscopic Guidance
CSF Collection:
Tube 1
Tube 2
Tube 3
Tube 4
Other Tests:
Opening Pressure:
Tests Requested:
Collected CSF:
to SMH lab
To Coordinator
to SMH lab
To Coordinator
to SMH lab
To Coordinator
to SMH lab
To Coordinator
cc
cc
cc
cc
Yes
No
Other Instructions: :
Biopsy with
CT
Ultrasound or
Fluoro Guidance
Large needle core biopsy Site:
Lymph Nodes:
Fine needle aspirate (FNA)
Bone Marrow
Other Organ/Body Part:
Nuclear Medicine Describe:
Other Imaging Exam/Procedure
Standard of Care Dictation OR
Clinical Trial Measurements:
Technologist Training:
Phantom Scan
Supplies to be Provided:
CSF Tubes
Tube Labels
CSF Lab Requisitions (as needed)
Other:
Collected Specimens:
To SMH Pathology
To Study Coordinator
Number Samples per Site:
Supplies Provided:
**You must provide Pathology Requisition
Describe:
FOR CANCER CENTER STUDIES
Lymph Nodes
Web- based
Onsite
Dummy or Volunteer Scan
RECIST 1.1
mRECIST
CHESON
ADDITIONAL REQUESTS
Travel to training site/meeting
Once - for imaging site certification
Deauville
Other:
Time Required for Training:
Before first subject exam of the day
Other:
Imaging Data Transmittal:
CD to Study Coordinator
Electronic
Other:
Completion of Study Forms:
Imaging Site Questionnaires
Data Transmittal Form
Exam Specific Worksheet
Other:
Exam Location(s):
SMH Inpt.
SMH Inpt. – Portable
SMH Outpt.
Science Park (UISP)
CC – Ortho
Imaging Protocol Attached?
Yes
Penfield
Red Creek
No IF NO, provide short description of exam(s) requested:
E-mail completed form and any attachments to JoAnne_McNamara@urmc.rochester.edu or fax to (585) 756-8290