DATE OF REQUEST   NAME OF TRIAL

 STUDENT ID DUPLICATE CREDENTIAL REQUEST FEE CHARGED
(JAWAPAN PADA SLAID) 1 A MANAGER REQUEST HIS
048B DATE OF BIRTHADDRESS CHANGE REQUEST FORM

2 REQUEST FOR NCG FUNDING FOR RITUXIMAB
2 REQUEST FOR URGENT CITIZENSHIP CEREMONY –
APPLICATION TO THE REGISTRAR TO REQUEST THE PRODUCTION

CLINICAL TRIAL REQUEST FOR IMAGING SERVICES


Date of Request:      


Name of Trial:      


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

Indication:       Frequency:      

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


Tags: request, trial