Form C
ACRF CANCER IMAGING FACILITY
BOOKING REQUEST FORM
Please complete this form and forward to cif@perkins.uwa.edu.au
Please attach:
- your AEC submission and approval letter.
- your permission to use unsealed radioactive substances in your laboratory if intending to remove
radioactive cadavers or organs from the Cancer Imaging Facility (CIF), including details of
transport.
- a list of the co-investigators who will attend the imaging sessions with their duties and
qualifications/experience with respect to animal care and isotope handling (do not include the CIF
Staff)
Your signature on this form indicates your agreement to acknowledge the ACRF CIF on any
presentations and publications arising from this work, and to forward copies of these to the CIF
Management Committee.
1. INVESTIGATOR’S DETAILS
Name:
CIF REF no (office use only):
Title:
Project Title:
AEC Approval No.
Hospital Dept/Research Centre:
Current Appointment:
Contact Details (email and telephone):
CIF invoices to be sent to (name, address, cost centre):
Planned/requested imaging date:
2. IMAGING MODALITIES REQUIRED
Please note that MRI and NUCLEAR MEDICINE IMAGING (PET OR SPECT) can operate
SEQUENTIALLY but not SIMULATANEOUSLY in an imaging session. EITHER PET-CT OR SPECT-CT will be
performed in an imaging session.
PET OR PET-CT
SPECT OR SPECT-CT
CT
MRI
MRI (tissue or cadavers only)
CT (tissue or cadavers only)
Radiopharmaceutical(s):
3. IMAGING PLAN AND PROTOCOL (please provide or attach a DETAILED workflow)
4. DATA ANALYSIS REQUIREMENTS
IMAGES ONLY
IMAGE INTERPRETATION BY SPECIALIST
QUANTITATION
PROVIDE DETAILS HERE:
SIGNATURE:
19 February 2015
DATE: