Diagnostic Imaging Impact Review
Study Name/Protocol Title:
PRINCIPAL INVESTIGATOR:
Date Sent to DI:
Provide a detailed review of all Impact and any costs to DI Department:
 Anticipated date of Start up
 Enrolment projected to end
 Anticipated number of subjects per month
per year
DIAGNOSTIC IMAGING
Standard
Not
of Care
Standard of
Care
Test
XRay
N/A
Departmental cost for
procedures that are
not standard of care
(to be completed by
DI)
(describe)
CT Scan
MRI
RECIST
Nuclear Medicine
(describe)
Angio or special
procedures
(describe)
Impact Analysis Completed by:
(Name/Title)
Version 5, dated October 6, 2015
Date
Diagnostic Imaging:
Agrees
Disagrees
to participate this trial.
__________________________
Dr. Scott Good, Clinical Director
_______________
Date
____________________________
Heather Gillis, Operations Director
_______________
Date
Note:
Impact signatures must be obtained from both the Department’s Clinical Director
and Operations Director.
Version 5, dated October 6, 2015