Image Response Assessment Teams (IRAT) Acquisition/Analysis
Questionnaire
Please submit to: kmkovaci@medicine.wisc.edu
PI Name: Click here to enter text.
Department/DOWG: Click here to enter text.
Contact Phone: Click here to enter text.
Contact Email: Click here to enter text.
Date: Click here to enter text.
What help do you need from IRAT (Check One)?
I only need imaging and/or image analysis services (e.g., multicenter trials)
Use Form A
I need assistance to effectively incorporate imaging (e.g., investigator initiated clinical trials)
Use Form A
I have an interesting research problem and I think imaging could help (e.g., grant proposals)
Use Form B
Assigned IRAT protocol submission number: IRAT00000
Contact information:
Katie Kovacich
608-262-8016
kmkovaci@medicine.wisc.edu
Form A: Imaging Consultation or Analysis Services Questionnaire
Please submit to: kmkovaci@medicine.wisc.edu
ADDITIONAL CONTACT INFORMATION
Statistician (statistician if known): Click here to enter text.
SPONSOR (Check One)
SUBMISSION DEADLINES
Scientific Review: Click here to enter text.
IRB Review: Click here to enter text.
STUDY INFORMATION
Type of study (diagnostic, treatment assessment, and pharmacodynamics): Click here to enter text.
Phase of study (i.e. I, I/II, II): Click here to enter text.
Treatment schema (drug name, days of administration, length of cycle, dose levels proposed): Click here to enter text.
Hypothesis/specific aims (main study hypothesis/specific aims): Click here to enter text.
PATIENT INFORMATION
Tumor (tumor type, stage, and nodal status, metastatic disease): Click here to enter text.
Organ systems (organ systems you wish to image): Click here to enter text.
Expected outcome (progression free survival (PFS), changed organ function): Click here to enter text.
Expected number of patients (approximate numbers, accrual frequency): Click here to enter text.
IMAGING INFORMATION
What do you expect from imaging? (What tissue characteristics/biological processes you would like to image): Click here to enter text.
Previous imaging studies performed at UW: Click here to enter text.
IF YES ONLY - Summary of previous imaging studies: Click here to enter text.
IF YES ONLY - What do you want to do differently this time: Click here to enter text.
Previous imaging studies outside UW (brief list/type of previous studies): Click here to enter text.
Standard of care imaging (diagnostic/follow-up imaging for all/some patients): Click here to enter text.
Anticipated imaging (imaging preferences): Click here to enter text.
Correlative studies (what other biomarkers are anticipated to be used): Click here to enter text.
DRUG INFORMATION
Drug combinations (single drug/multiple drug): Click here to enter text.
Mechanism of action (MOA) (key cellular molecular mechanisms): Click here to enter text.
Pharmacokinetic, pharmacodynamic parameters (drug half-life): Click here to enter text.
Assigned IRAT protocol submission number: IRAT00000
Contact information:
Katie Kovacich
608-262-8016
kmkovaci@medicine.wisc.edu
Form B: Imaging Collaborator Questionnaire
Please submit to: kmkovaci@medicine.wisc.edu
ADDITIONAL CONTACT INFORMATION
Statistician (statistician if known): Click here to enter text.
SPONSOR (Check One)
GRANT SUBMISSION DETAILS
Grant type: Click here to enter text.
Submission deadline: Click here to enter text.
Budget: Click here to enter text.
Approximate imaging budget: Click here to enter text.
RESEARCH PROPOSAL
Type of study (diagnostic, treatment assessment, and pharmacodynamics): Click here to enter text.
Tumor (tumor type (primary, nodes, metastases)): Click here to enter text.
Organ systems (organ systems you wish to image): Click here to enter text.
Treatment (drug, combination): Click here to enter text.
Hypothesis/specific aims (main research hypothesis/specific aims): Click here to enter text.
IMAGING INFORMATION
What do you expect from imaging (what tissue characteristics/biological processes you would like to image): Click here to enter text.
Previous imaging studies performed at UW: Click here to enter text.
IF YES ONLY - Summary of previous imaging studies: Click here to enter text.
IF YES ONLY - What do you want to do differently this time: Click here to enter text.
Previous imaging studies outside UW (brief list/type of previous studies): Click here to enter text.
Standard of care imaging (diagnostic/follow-up imaging for all/some patients): Click here to enter text.
Anticipated imaging (imaging preferences): Click here to enter text.
Anticipated collaborators (if known (previous contacts)): Click here to enter text.
Correlative studies (what other biomarkers are anticipated to be used): Click here to enter text.
DRUG INFORMATION
Drug combinations (single drug/multiple drug): Click here to enter text.
Mechanism of action (MOA) (key cellular/molecular mechanisms): Click here to enter text.
Pharmacokinetic, pharmacodynamic parameters (drug half-life): Click here to enter text.
Assigned IRAT protocol submission number: IRAT00000
Contact information:
Katie Kovacich
608-262-8016
kmkovaci@medicine.wisc.edu