Date of Request: |
|
||||||||||
|
|||||||||||
Principal Investigator: |
Billing Administrator: |
Ph./Ext #: |
Box #: |
||||||||
Study Coordinator: |
Ph.: Pager: |
Other Coordinator: |
Ph.: Pager: |
||||||||
Trial Sponsor: NIH Industry Other: |
Billing Company: Spend Category: FAO/Grant #: |
||||||||||
RSRB#: |
Est. # Subjects: |
Est. Start Date: |
Est. End Date: |
||||||||
*Requested Exams/Procedures – Billable to the Study Ledger *SOC image acquisition & dictation will be followed unless otherwise requested* |
|||||||||||
Fill in all information as requested. Check all that apply |
|||||||||||
Plain Film X-ray Body Part(s): View(s): Indication: Frequency: |
|||||||||||
Ultrasound Organ/Body Part(s): Doppler: With Without Indication: Frequency: . |
|||||||||||
PET CT: Eyes to Thighs Vertex to Thighs Vertex to Toes (Whole Body) Brain Other: Indication: Frequency: |
|||||||||||
Nuclear Medicine: Indication: Frequency: |
|||||||||||
MRI Scan Magnet Strength: 3T 1.5T Contrast: Without Without & With MR Spectroscopy MR Angiogram fMRI (brain) MR Perfusion DCE MR Perfusion ASL MR DTI Indication: Frequency: CT Scan Contrast: With Without Without & With CT Angiogram CT Perfusion CT Myelogram |
BODY PART(S) Head/Brain Neck Chest Abdomen Pelvis Musculoskeletal: Spine: Cervical Thoracic Lumbar Sacrum Organ/System: Esophagus Stomach Liver Kidney Other: Lymphatics: Vascular System: Venous Arterial Vessels: |
||||||||||
Lumbar Puncture CSF with Fluoroscopic Guidance CSF Collection: Tests Requested: Collected CSF: Supplies to be Provided by Study Team: Tube 1 cc to SMH lab To Coordinator CSF Tubes Tube 2 cc to SMH lab To Coordinator Tube Labels Tube 3 cc to SMH lab To Coordinator Other: Tube 4 cc to SMH lab To Coordinator Opening Pressure: Yes No Other Instructions: Indication: Frequency: |
|||||||||||
Large Needle Core Biopsy* Fine Needle Aspiration* *CT, Ultrasound or Fluoro Guidance as per interventionalist Site: Lymph Node Liver Lung Other: Tissue Requested: Standard Care Core Core in addition to Standard Care Sample Core for research purposes only Sampling Instructions: As per Standard Care As per Study Protocol: Needle Size: Minimum # Passes: Minimum # Samples: OR Minimum Sample Size: Other: Tissue Handling: As per Standard Care (lymphoma samples placed in saline, most others in 10% NBF) As per Study Protocol: Supplies Provided by Study Team: No Yes: Tissue Disposition: IR staff to bring SOC samples to Surg Path (for routine processing & reporting). Study staff must pick-up all STUDY samples Indication: Frequency: |
|||||||||||
Other Imaging Exam/Procedure: Indication: Frequency: |
|||||||||||
ADDITIONAL REQUESTS Technologist Training: Web-based Onsite Travel to training site/meeting Time Required for Training: Site Certification Scan: Dummy or Volunteer Scan Phantom Other: Imaging Data Transmittal: CD Electronic by Study Team Electronic by Imaging Staff Other: Completion of Study Forms: Imaging Site Questionnaires Data Transmittal Form Exam Specific Worksheet Other: Advanced Image Post-Processing (image reformatting, quantitative analysis, etc. |
|||||||||||
Exam Location(s): SMH Inpt. SMH IR East River Rd CC Ortho Penfield Red Creek Strong West GCH |
|||||||||||
Protocol/Imaging Manual Attached? Yes No IF NO, provide description of exam(s) requested: |
Completed form & attachments to: [email protected]
CHAIRMAN PHIL MENDELSON AT THE REQUEST OF THE
FREEDOM OF INFORMATION ACT REQUEST PLEASE REVIEW
FRESNO COUNTY EMPLOYEES’ RETIREMENT ASSOCIATION REQUEST FOR PROPOSAL