The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

KTD2wXgocKXyaidF2Ft689Ae3fw3CvrBMsiY4L6ZYdM3hwvvL2tUemQmjwUQKyXF37J5cpSdxGIjG3h8cxnz5RXmJY8owHoC6A5JU8

Radiology Resource Utilization Intake Form: Page 1

Please complete the following survey regarding use of Department of Radiology and/or Imaging Research Center (IRC) resources.

The information collected in this form facilitates planning for upcoming studies and establishing processes and protocols necessary for successful study completion. The collected information will also be used to generate a budget for study related costs.

Completion of this form does not substitute for IRB or IACUC approval. Both IRB/IACUC approval and approval of the Radiology Department are required before study activities can begin. You will receive notification when the Radiology Department has approved your resource request.

Failure to complete this form will result in delayed availability of imaging resources.

Please click the link below to access a guide to aid with the completion of this form:

Guide for end users (USER)

If you have a questions about the Radiology Department intake process or this form contact: imagingresearch@cchmc.org

Principal Investigator's Name

* must provide value

Principal Investigator's Institution

* must provide value

Institution

* must provide value

Principal Investigator's Department

* must provide value

Principal Investigator's Department

* must provide value

OTHER

Principal Investigator's Email

* must provide value

Principal Investigator's Phone Number

* must provide value

Are you the study PI?

Yes

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Submitter's Information:
Name
Role in Project
Email

* must provide value

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Does your study use only existing imaging data (i.e., is it a retrospective study)?

* must provide value

Yes

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Is your study a multi-center study?

* must provide value

Yes

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My subjects are

* must provide value

Humans

Animals

Phantoms

Specimens

Other

Lead institution or sponsor:

* must provide value

Have the terms of your study been negotiated/approved by the CCHMC Office for Clinical and Translational Research (OCTR)

Yes

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I will be using (select all that apply):

* must provide value

Imaging Research Center (IRC) equipment

Clinical Equipment

What do you plan to scan?

* must provide value

Enter the study title:

* must provide value

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Clinical coordinator/scheduling person name:

* must provide value

Clinical coordinator/scheduling person email:

* must provide value

Are you working with a CCHMC Radiology faculty/staff member?

* must provide value

Yes

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Enter the name(s) of the Radiology faculty/staff.

* must provide value

Please list all study tasks that ______ will be helping with:

* must provide value

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Provide a brief description of the study purpose and aim(s). It must include all imaging hypothesis. "See attached protocol" is not acceptable.

* must provide value

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Anticipated start date:

D-M-Y

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.