RIF Research Application #
(For office use only)
University of Oklahoma Health Science Center
College of Pharmacy, Research Imaging Facility
RIF Application
(This is form can be filled using MS-Word)
1) Date:
New application:
Renewal:
(RIF Research Application #: _______NA_____ )
2) Project Title: __________________________________________________________________
3) Principal Investigator*:___________________________________________________________
Institution/Company: __________OUHSC__________________________________________________
Phone:_______________
4) Imaging Modalities Requested:
E-Mail:_______________
PET
SPECT
5) Longitudinal imaging studies*?
CT
6) Post-imaging biodistribution studies?
8) OUHSC Budget Code, if any:______________________________________________________
9) PI Signature: _______________________________________
Date: _________________
By signing this application the PI gives RIF permission to bill the identified grant for the instrument time at the
rate of $250 an hour. The charges for agents, radiopharmaceuticals and time to perform biodistribution study will
be discussed with the facility director on case by case basis. The PI also confirms that personnel working on
this project have completed all required animal handling, lab safety and radiation safety training.
THIS SECTION TO BE FILLED OUT BY THE FACILITY DIRECTOR
DATE OF REVIEW: __________ APPROVED: No
Yes
EXPIRATION DATE:_________
REASON(S):_____________________________________________________________________________
________________________________________________________________________________________
ANIMAL USE: YES / NO
LONGITUDINAL: YES / NO
Approximate Duration _____ days
IACUC PROTOCOL _____________ EXPIRATION DATE___________
FUNDED: YES / NO
PROJECT ID: ____________ACCOUNT CODE : __________________
SIGNATURE:___________________________________ Date:_____________________________
*Definition of longitudinal imaging studies: Any animal on whom: A) more than one imaging procedure
will be performed; and/or B) the imaging procedures will take place on more than one day.
Form-RIF
Revised on 4/7/2014
10) Primary User(s) (other than the PI):
Name
Campus Phone
E-Mail
11) If funding is available for this project, provide the following information about the funding source.
Name of P.I.: ___________________________
Funding Agency: _____________________
Grant number :__________________________
Account Number:_____________________
Contact Person: _________________________
Phone: _____________________________
12) If this project is not funded, are you requesting time for PILOT STUDY?
*If yes, give a brief explanation of how you plan to pursue funding in the future.
No
Yes
13) For non-OUHSC investigators, please provide details of the person to whom billing should be sent.
Name: ________________________ Phone number: _____________ e-mail:___________________
Department and Institution:_____________________ Address:_______________________________
14) Describe how you plan to use these facilities, your imaging protocol, including numbers of animals,
numbers of scans, etc. Indicate specific needs regarding data acquisition or image reconstruction.
It is strongly encouraged that the imaging study is discussed with facility director. Contact: Dr.
Awasthi, PhD, Email: vawasthi@ouhsc.edu , CPB 309, (405) 271 6593 X47331
15) PET, SPECT, CT Nuclear Imaging:
PET
SPECT
CT
Radioactive material (and/or contrast agent):_ _____________________________________________
Anesthesia: Isoflurane
Oxygen
Injectable Anesthetics
(_________________________)
*Most tracers will be available through the Nuclear Pharmacy or synthesized in-house in the College of
Pharmacy. If radioactive tracers will be brought in from other sources, please provide the name of the
radiation license holder_______________________.
Form-RIF
Revised on 4/7/2014
2
16) Will any hazardous materials other than radioactive tracers be brought into the imaging facility
during this project?
No
Yes
If yes, identify the materials, describe the hazards and provide handling instructions.
17) Does this research involve animals? No
Yes
IACUC Approval
If yes, answer the following questions and attach a copy of the IACUC approval letter and the
IACUC protocol under which imaging studies will be performed to each copy of this application.
IACUC Protocol Number: ___________
Longitudinal Studies: No
Protocol expiration date: ________________
Yes
Animal transfer/holding approval*:
Yes
Estimated stay in the facility:_______(days)
*Please discuss with the staff in Department of Comparative Medicine and get necessary
approval for animal transfer and holding in the College of Pharmacy.
Important
Please deliver this application and all associated documents to
College of Pharmacy Building, Room number 31, 1110 North Stonewall Avenue, Oklahoma City 73117
Ph: (405) 271-6593 Ext. 47284, E-mail: andria-hedrick@ouhsc.edu
Fax: (405) 271-7505
Form-RIF
Revised on 4/7/2014
3