DEPARTMENT OF RADIOLOGY
Research Procedure Request Form
(Complete when planning/requesting radiological procedure for research studies)
Quote Only (Please fill in 1-10a)
Request Date:
Formal Request (Please fill in 1-10b)
Title of Study:
Start Date:
End Date:
1. Principal Investigator:
Dept.
Ph/fax:
Pager:
2. Contact Person:
Dept.
Ph/fax:
Pager:
3. Alternate Contact Person:
Dept.
Ph/fax:
Pager:
4. Physician on Study:
Dept.
Ph/fax:
Pager:
5. Name of the Radiology faculty member associated with this study:
6. Description of Research Study (please be brief):
7. Description of Requested Imaging Services (include CPT code) – describe Radiology involvement in the research study.

Location of study to be performed:
Main Hospital
ACC

Preferred time of study:
AM
PM
Weekend
Time requirements of procedure:

Modality requested:
CT
MRI
Diagnostic
Ultrasound
Interventional
Mammo



Other:
Nuclear
DEXA
Vascular Lab
Anticipated No. of Patients:
Procedure(s) requested:
CPT Code(s):
# of exams per patient:
9. List any special requirements of Radiology services :
none
scheduling
special reports
special views
Explanation for item(s) selected:
Image storage requested:
Routine Procedure
Image transfer:
yes
10a. Type of Research requested:
Film
Videotape
Disk
DAT
new pulse
sequences
Special Formatting
no
Funded study with report
Funded blind study
NOTE: The Department of Radiology will no longer provide services for human research patients without a valid UCDHS
medical record number. It is the responsibility of the referring department to ensure that the patient is properly registered.
10b. List Funding Source(s) for Radiology services:
NIH Grant
Private Sponsor
Professional Society
Dafis Funding:
Chart:
Radiology Research Vice Chairman:
Account:
Other (specify):
Sub Acct:
Object:
FOR RADIOLOGY DEPARTMENT USE ONLY
Radiology Imaging Manager:
_____________________________________________________
Signature
Date
BILLING INFORMATION:
UCD/UCDMC
______________________________________________
Signature
Date
Comments:
Please return completed form to: Radiology Research Committee (RRC), Research Administrative Assistant, Imaging Center,
UCDMC
Phone: 734-3651
FAX: 734-0316
DEPARTMENT OF RADIOLOGY
IMPORTANT INFORMATION & REQUIRED DOCUMENTATION FOR
CLINICAL RESEARCH STUDIES
The Department of Radiology supports and encourages clinical research at UCDMC. Requests for
clinical studies are reviewed by the Clinical Research Committee who give specific attention to patient
safety, scheduling, procedure modification requests, any non-routine requirements of requested
services, image storage and transfer requirements, and reimbursement of procedure charges.
Investigators (PIs) should request procedure charge rates before submitting a new research/grant
budget that includes Radiology services.

The Department of Radiology highly recommends the PI work with a specific radiologist to
discuss the research study. This will help determine procedures required and assist with more
accurate cost estimates.

Non-Routine Imaging Procedures: All research protocols/studies that involve non-routine
imaging studies, e.g. studies involving modified acquisition, processing, analysis, display, and/or
storage, must be reviewed and approved prior to study initiation.

Procedure Fees/Cost Information: Information provided on The Department of Radiology
Research Procedure Request Form will be used to determine pricing information and to develop
a quote for research studies in the Department of Radiology. A quote is often requested by
PIs/Clinical Coordinators in the planning stages of a study before the time that a contract is final.
Unless the study is initiated immediately, the PI should be aware that pricing/costs might
change.
Required Documents:
All investigators (PIs) planning to conduct research studies involving patients and/or volunteer
subjects on imaging equipment in Radiology are required to file the following forms with the
Department of Radiology:
Please use the check-off boxes below for items required by the Department of Radiology.
1. Completed Department of Radiology Research Procedure Request Form.
2. Copy of protocol.
3. Copy of Human Subjects Review Committee (aka IRB) approval.
IRB requirements include Radiation Use Committee (RUC) approval. Contact Lorraine Smith,
losmith@ucdavis.edu. This committee is separate from the Dept of Radiology.
4. Copy(s) of consent form(s).
5. Copy of the approved UCDMC Bulk Account Application Form with the Dafis
account number.
Send items to:
Radiology Research Committee (RRC)
c/o Research Administrative Assistant
Imaging Center, 4701 X St., UCDMC
Phone: 734-3651
Fax: 734-0316
5/03
UNIVERSITY OF CALIFORNIA, DAVIS
BERKELEY  DAVIS  IRVINE  LOS ANGELES  RIVERSIDE  SAN DIEGO  SAN FRANCISCO
SANTA BARBARA  SANTA CRUZ
DEPARTMENT OF RADIOLOGY
UC DAVIS HEALTH SYSTEM
RESEARCH IMAGING CENTER
4701 X STREET
SACRAMENTO, CALIFORNIA 95817
J. ANTHONY SEIBERT, Ph.D.
PROFESSOR OF RADIOLOGY
PHONE
916-734-0311
FACSIMILE
916-734-0316
EMAIL jaseibert@ucdavis.edu
(as of) May, 2002
To all principal investigators using Radiology imaging services for research:
The Department of Radiology will no longer accept research patients without a valid medical record number or
proper registration through the department or research group requesting the study. The study coordinator (or
designate) must fill out the pink radiology request form* (specifically used for reduced procedure charges for
approved research studies) to ensure timely registration and scheduling through the Radiology Information
System. For studies that are required to be anonymous, the patient name can be coded (after the information has
been digitally archived) prior to delivery of digital images or film.
This change is necessitated by the digital archive database to avoid lost studies and for medico-legal
protection if other inadvertent findings are noticed on the images during interpretation.
Should you have any questions regarding this policy change, please contact the Radiology Research
director.
* Pink radiology request CalCode # 70000-436 (3/99)