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:
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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