Ra di ol ogy Res earch Ap pl i cati on Form RV 12. 3. 2014 (fi nal ) Radiology Clinical Research Application Form HMC / SCCA / UWMC Purpose of This Form: The Radiology Clinical / Research Application Form is required for the use of the clinical imaging service (s) and device (s) at University of Washington Medical Center (UWMC), Harborview, Roosevelt and Seattle Cancer Center Alliance (SCCA) in the department of Radiology. Clinical trial studies that generate medical information from research and clinical images need to be conducted at the medical centers. Please Note: This form is only for use for whole live human subjects. Cadavers and fossils, please contact Margie Lawrence directly at margiel@uw.edu. If the proposed research protocol does not use clinical imaging scanners in medical centers (UWMC, HMC, or SCCA), DO NOT complete this form. Instead, contact the manager of the dedicated research center listed below for their review and pricing information. BMIC (Dedicated Research 3T MRI) DISC (Dedicated Research 3T MRI) PET/CT (Dedicated Research PET/CT) BioMedical Imaging Center Jennifer Newcomb Radiology, South Lake Union 850 Republican Street Seattle, WA 98109 Phone number: 206-616-1697 Diagnostic Imaging Science Center Liza Young Radiology, UW Health Sciences Box 357115 Phone number: 206-685-0457 Barbara Lewellen Radiology, Harborview Medical Center Phone number: 206-598-5523 Email: barblewe@u.washington.edu Email: liza14@u.washington.edu Email: newcomb@u.washington.edu Radiology Clinical Research Contacts: CONTACT Radiology RADRRR Application Process (UWMC, Roosevelt, HMC) PHONE 206-616-0962 EMAIL radrrr@uw.edu SCCA Research Implementation Office (RIO) 206-288-7116 CRBB RRR Budgets https://depts.washington.edu/crbb/Form s.shtml 206-543-7774 RECIST Reads/OncoRad/TIMC Pricing Listing and Billing Procedure for Tumor Measurement 206-598-9322 drguay@uw.edu 206-685-5313 or 206-543-0463 ehsdept@uw.edu UWMC Radiation Safety Compliance Office http://www.ehs.washington.edu/ http://www.ehs.washington.edu/forms/in dex.shtm Page 1 of 5 rio@seattlecca.org crbudget@u.washington.edu Ra di ol ogy Res earch Ap pl i cati on Form RV 12. 3. 2014 (fi nal ) UW MEDICINE RADIOLOGY CLINICAL RESEARCH APPLICATION FORM HMC/SCCA/UWMC TO FACILIATE AND REVIEW YOUR PROPOSAL FOR FEASIBILITY, APPROVAL, AND ESTIMATED RESEARCH PRICING BY THE RADIOLOLGY RRR PRICING & REVIEW COMMITTEE, PLEASE COMPLETE THE FOLLOWING QUESTIONNAIRE Request Date: Principal Investigator Name: Co-Principal Investigator Name (if applicable): Department: Protocol Number or Study Title: Grant/Contract Number (if applicable) : Budget number and/or eGC1# (if available): Flow-through: Sponsor: No Yes If yes, prime sponsor: Study Contact: Email: Phone: PLEASE PLACE “X” IN ONE OF THE FOLLOWING BOXES Pricing for CRBB RRR Account (Clinical Research and Billing) Preliminary price estimate only (These prices cannot be used to obtain the RRR Account from CRBB) 1. Clinical Resources Location: (Please enter “X” in the box next to all proposed sites) HMC SCCA UWMC ROOSEVELT 2. Is any Radiology investigator already involved in the planning of your project? If “Yes”, please give the Radiology investigator’s name. (The feasibility review process will determine if radiologist involvement is required. NO YES Name Individual(s): Most studies require interpretation by a clinical radiologist. Have you arranged for this? NO YES Please specify: Does the radiologist have paid effort on the study? NO YES Please specify: Is the radiologist a co-investigator? NO YES Please specify: Page 2 of 5 Ra di ol ogy Res earch Ap pl i cati on Form RV 12. 3. 2014 (fi nal ) 3. What specific imaging is requested? Please enter “X” for each requested modality and check the box for the location(s). Include any specific procedures require d for each image. Biopsy Location: UWMC SCCA HMC Specific Anatomical areas of interest (please select all that apply): Kidney/Renal CT US CT/US Liver/Hepatic CT US CT/US Lung/Mediastina (chest) CT US CT/US Lymph Node CT US CT/US Bone: Deep (hip or femur/thigh bone) CT US CT/US Bone: Superficial (ilium or sternum) CT US CT/US Muscle/soft tissue CT US CT/US Ovary CT US CT/US Pancreas CT US CT/US Prostate CT US CT/US CT US CT/US Other (Please Specify): Other techniques required (e.g. special reconstruction or post processing ): Angiography (Interventional Imaging) Location: UWMC SCCA HMC Specific Anatomical areas of interest (please specify): Procedure Descriptions: Other (please specify): Other techniques required (e.g. Functional anatomical, diffusion weighted, angiography, unique for qualifications, different sequences or dynamic, etc.): CT Location: UWMC SCCA HMC Specific Anatomical areas of interest (please select all apply): WO=without contrast; W=with contrast; WOW= without and with contrast Brain WO W WOW Head WO W WOW Neck WO W WOW Cardiac WO W WOW Chest WO W WOW Abdominal WO W WOW Pelvis WO W WOW Lumbar Spine WO W WOW Thoracic Spine WO W WOW Upper Extremity WO W WOW Lower Extremity WO W WOW Other (Please Specify): WO W WOW Other techniques required (e.g. special reconstruction or post processing ): Specific CT equipment or functions required: (e.g. High definition cardiac, dual energy, perfusion, etc.): Phantom required: No Yes Frequency (please specify): Page 3 of 5 Ra di ol ogy Res earch Ap pl i cati on Form MRI Location: RV 12. 3. 2014 (fi nal ) UWMC SCCA HMC Specific Anatomical areas of interest (please select all apply): WO=without contrast; W=with contrast; WOW= without and with contrast Brain WO W WOW Head WO W WOW Neck WO W WOW Cardiac WO W WOW Chest WO W WOW Abdominal WO W WOW Pelvis WO W WOW Lumbar Spine WO W WOW Thoracic Spine WO W WOW Upper Extremity WO W WOW Lower Extremity WO W WOW Bone Marrow WO W WOW WO W WOW Other (Please Specify): Are there specific MRI techniques, sequences, or functional parameters required beyond a standard clinical MRI (e.g. 1.5T, 3T, diffusion weighted, dynamic, cardiac specifics, or angiography)? Other techniques required (e.g. special reconstruction or post processing ): Other specific technique required (e.g. Functional , anatomical, diffusion weighted, angiography, unique for qualifications, different sequences or dynamic, etc.): Phantom required: PET/CT Location: No UWMC Yes SCCA Frequency (please specify): HMC Please Note: For HMC PET-CT, if imaging procedures are paid by research funding/account, STOP – DO NOT complete this form. Instead, please contact the Director of Nuclear Medicine, Radiology, Dr. David Lewis, at lewis@uw.edu Specific Anatomical areas of interest (please specify): Type of Tracer (S): Other specific techniques required (e.g. dynamic, etc.): Phantom required: No Nuclear Medicine Location: UWMC Yes SCCA Frequency (please specify): HMC Specific Anatomical areas of interest (please select all apply): Whole body Tumor MUGA SPECT Type of Tracer (S): Other (please specify): Other techniques required (please specify): Ultrasound Location: UWMC ROOSEVELT HMC SCCA Specific Anatomical areas of interest (please select all apply): Liver OB (which trimester): Duplex/Doppler: Abdomen Vascular Kidney Non-vascular Bilateral Extremities (upper/lower): Other (please specify): Procedure/exam description: Phantom required: No Yes Frequency (please specify): Page 4 of 5 Unilateral Ra di ol ogy Res earch Ap pl i cati on Form RV 12. 3. 2014 (fi nal ) Radiologic Diagnostic Location: UWMC ROOSEVELT HMC SCCA Specific Anatomical areas of interest (please specify): Number of Views: Specific requirements (e.g. dual energy, tomosynthesis, etc.) : Other techniques required (please specify): Phantom required: No Yes Frequency (please specify): DXA or DEXA Diagnostic (Dual energy X-Ray absorptiometry) Location: UWMC ROOSEVELT HMC SCCA Specific Anatomical areas of interest (please select all apply): Axial (Hips/Spine) Peripheral (append, wrist) Vertebral fracture assessment Body composition Other (please specify): Other techniques required (please specify): Phantom required: No Yes Frequency (please specify): 4. Number of proposed subjects/years of study/scan per subject. Number of Subjects: Number of Years: Number of Scans per Subject: 5. Is the proposed procedure identical to a standard clinical protocol? If "No", pl ease indicate the specific sequencing. (Feasibility review process will determine if identical to a standard protocol.) NO YES Please specify: 6. Is the study supplying pharmaceuticals or devices for this proposal? NO YES Please specify: 7. Quality Control, Site Qualifications, or Image Data Management. Are there specific quality control procedures, site qualifications, or imaging data management being requested? If “Yes” please answering the following: NO YES Initial site evaluation form? No Yes Frequency Describe the specific procedures required. Who will perform this work? Are there specific QC measures that must be done? No Yes Frequency How often must the QC be repeated? Does the QC need to be sent to another site? No Yes Frequency a. Will the images be collected and sent for review to a central imaging facility? No Yes b. If imaging data collected, what transmission media will be used? (e.g., CD, Flash drive, secure internet, etc.). Have you arranged for transfer of the imaging data? (Shipping, data transmission, etc.). Please specify: Are measurements of tumors, such as RECIST reads, required? Yes No (If yes, please contact Diane Guay at 206-598-9322 or drguay@uw.edu for pricing and billing procedure) HMC Clinical Resource Location SCCA Clinical Resource Location UWMC Clinical Resource Location Please submit the following documents as an attachment by email to Please submit with the following documents as an attachment by email to Please submit the following documents as an attachment by email to This form Copy of the protocol Contact: Radiology Research Committee Box 359728 Voice mail: 206-744-8761 Fax: 206-774-8560 This form Copy of the protocol Contact: Radiology Research Committee Box 354807 Voice mail: 206-616-0962 Fax: 206-685-9096 radrrr@u.washington.edu RIO@seattlecca.org This form Copy of the protocol SCCA RIO Submission Form SCCA Pricing Table Request Clinical Trial Activity Summary (CTAS) Contact: SCCA Research Implementation Voice mail: 206-288-7116 Fax: 206-288-6817 Page 5 of 5 radrrr@u.washington.edu