ࡱ> { =bjbjxx 4ffLLLLL```8|`hJ !N# I I I I I I I$JLOL1IL(  ((1ILL4J&+++(LL I+( I++GDF lk(EH,J<hJ-ELOZ)0LO4FLOLFH$$+%$&$$$1I1I*$$$hJ((((LO$$$$$$$$$X :  A. Project Title: FORMTEXT       B. Short Title (30 characters max.): FORMTEXT       Note: Title should be generic for the online schedule that is viewable by the general public. C. Anticipated Start Date: FORMTEXT       Projected End Date: FORMTEXT       D. Name of the Principal Investigator Name: FORMTEXT       Title: FORMTEXT       Dept: FORMTEXT       Box: FORMTEXT       Address: FORMTEXT       Phone: FORMTEXT       Fax: FORMTEXT       Email: FORMTEXT        E. Name of the Primary Contact Person Name: FORMTEXT       Title: FORMTEXT       Dept & Box: FORMTEXT       Address: FORMTEXT       Phone: FORMTEXT       Fax: FORMTEXT       Email: FORMTEXT        Please check one:  FORMCHECKBOX  F. Funded Research Project Budget InformationIf a funded project with a UW budget, please complete the information below: UW Budget Number: FORMTEXT       Budget Name: FORMTEXT       Source of Funding: FORMTEXT       Duration of Funding: Start date  FORMTEXT       End date:  FORMTEXT       If a funded project, but not affiliated with the University of Washington, please provide the following: P.O. #: Billing information:   Brief summary of the proposed project. 1) Objectives:  FORMTEXT      2) Research Plan:  FORMTEXT       H. Will human subjects be used in this study?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, do you have consent form?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Pending If yes, please attach copy of approved consent form. Your IRB study number: Dates of Approval: From: To: If no, please state if using you are testing coils and using phantoms:  I. Will animals be used in this study:  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, give your approval number and request form for animal studies:  J. Will MRI contrast agents such as gadolinium be used?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If gadolinium or other contrast will be used, do subjects require creatinine test (kidney function) prior to MR scan?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Will other medications be administered for this study?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes to either contrast or medication adminigstration, please identify the WA State licensed MD to cover injections and/or drug administration: Dr. (Full name) Note: Our center is currently not responsible for providing injection coverage  K. Will radiotracers be used in this study?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, name of licensee: FORMTEXT       and License number: FORMTEXT       In an attached document, please describe their use, amounts, and the procedures to be followed to prevent contamination of the MRI equipment and facility. Note: Restrictions apply to the location and usage of radioactive materials. The licensee will be responsible for clean up and removal of all radioactive materials after each experiment; no facilities at the BMIC are available for storage of radioactive materials. Will hazardous chemicals, inhalational anesthetics, or infectious agents be used in this study?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, describe the precautions in an attached document M. Will bring any equipment into the MRI facility?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, is the equipment MR compatible?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Also, please list equipment: Note: Prior written approval for any equipment brought into the MR center is necessary for the safety of personnel and equipment. This approval is in addition to overall study approval. N. Duration and number of scanning sessions requested. (Note: If you are not certain about scan duration and number of sessions, please contact BMIC prior to submission:  HYPERLINK "mailto:bmic@uw.edu" bmic@uw.edu or Zach Miller  HYPERLINK "mailto:zach1@uw.edu" zach1@uw.edu Duration for each scan session (a)  FORMTEXT       Hours Number of sessions requested (b)  FORMTEXT       SessionsO. Planned MR protocol. All MR protocols must be reviewed and approved by BMIC personnel. For protocol questions please contact  HYPERLINK "mailto:bmic@uw.edu" bmic@uw.edu or Niranjan Balu  HYPERLINK "mailto:ninja@uw.edu" ninja@uw.edu Study has existing standard protocol exam card compatible with Philips scanner:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Study has existing custom protocol exam card compatible with Philips scanner:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Study has protocol exam card not compatible with Philips scanner (GE, Siemens, etc):  FORMCHECKBOX  Yes  FORMCHECKBOX  No Study has no protocol, needs assistance with protocol development:  FORMCHECKBOX  Yes  FORMCHECKBOX  No List MR sequences included in protocol:  FORMTEXT        P. BMIC Policies: Any modification to the existing protocol that changes the risks and/or procedures must be formally submitted for approval as an addendum to this application (e.g. replacing equipment, new drugs, new MR protocols or coils, etc.) Billing: MR scans for internal human or animal UW studies will be billed at a rate of $664/hour. Consulting services will be billed at a rate of $219/hour. Other services will be billed according to rates in Administrative Use section below. Please note that scan pricing is set by the University and subject to change. 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Scans that fail due to subject motion or subject no-shows will be billed for the full time booked for scans during normal business hours (8 am -5 pm, M-F) and for the amount of time used for after-hours scans, billable in 15 minute increments. Safety Procedures: Safety training and certification must be completed as specified on the center website prior to study personnel participating in MR scans.  I attest that the information provided in this application is current and accurate. I will adhere to the center scan and billing policies as outlined here and ensure financal responsibility for the cost of the study. Name of Principal Investigator: (Print) (Signature) Date Q. Optional: please tell us how you heard about the Bio-Molecular Imaging Center:  FORMTEXT        Administrative Use OnlyA. Date application received: Study Number: B. Cost for the use of the BMIC 3T scanner: $ /hour x hours/each session=a): $ Total sessions=b): Total cost for the entire imaging study: a) x b) $ Hourly Pricing for Services: Consulting Service - $219/hour $ Internal Human Scan- $664/hour $ Off hour service fee - $108 $ Charges for requested supplies Contrast - $105/unit (20cc vial) $ Physician Contrast Coverage - $50/ea $ Istat (creatinine) testing - $62/ea $ Data Service $35 $ TOTAL SUPPLIES $ C. Reviewed and approved by the BMIC director Chun Yuan, PhD Signature Date  Please submit this application as well as any requested documentation as a signed PDF document to Bio-Molecular Imaging Center,  HYPERLINK "mailto:bmic@uw.edu" bmic@uw.edu or Zach Miller  HYPERLINK "mailto:zach1@uw.edu" zach1@uw.edu     Bio-Molecular Imaging Center (BMIC) University of Washington South Lake Union CampusApplication for RESEARCH Protocol Project #YY-NNNN850 Republicanzzzzzz h$Ifgd+ hgdivnkd/$$Ifl0** t0644 lap yt+:GMN_hy޴ޣޑn]L h+h>8CJOJQJ^JaJ h+hLTCJOJQJ^JaJ h+h CJOJQJ^JaJ#h+h >*CJOJQJ^JaJ#h+h.>*CJOJQJ^JaJ h+h.CJ OJQJ^JaJ h)?CJOJQJ^JaJhkBCJOJQJ^JaJh!!CJOJQJ^JaJ h+h.CJOJQJ^JaJ h+hBICJ OJQJ^JaJ  24Vzzzzz h$Ifgd+ hgdivnkdK0$$Ifl0** t0644 lap yt+ !".:qrs}~ òx`EEEEE4jh+hq`CJOJQJU^JaJmHnHu/j0h+hq`CJOJQJU^JaJ h+hq`CJOJQJ^JaJ)jh+hq`CJOJQJU^JaJ&h+h056CJOJQJ^JaJ hq`56CJOJQJ^JaJ#hq`hq`5CJOJQJ^JaJhb5CJOJQJ^JaJhCJ OJQJ^JaJ h_/CJ OJQJ^JaJ  24VXZ\^PRTڷuduRuRAduAR h+hLTCJOJQJ^JaJ#h+hLT>*CJOJQJ^JaJ h+h>8CJOJQJ^JaJ#h+hLT5CJOJQJ^JaJ h+hJ`CJ OJQJ^JaJ h+h_/CJ OJQJ^JaJ h_/CJ OJQJ^JaJ h+h>8CJOJQJ^JaJ#h+h0>*CJOJQJ^JaJ#h+h_/>*CJOJQJ^JaJ&hq`h056CJOJQJ^JaJVXZ\^s$ hxx$Ifa$gd+ hgdivnkdC1$$Ifl*+ t0644 lap yt+p hxx$Ifgd+~kd1$$Ifl0**  t 0644 l` ap yt+Pt\ttt h8a  $Ifgd+ h$Ifgd+~kdf2$$Ifl0**  t 0644 l` ap yt+TVdhv<\]ܸܸʔo`RDh;nCJOJQJ^JaJh)?CJOJQJ^JaJh)?5CJOJQJ^JaJ h+h>8CJOJQJ^JaJ&h+h3?5>*CJOJQJ^JaJ#h+h3?5CJOJQJ^JaJ#h+hLT>*CJOJQJ^JaJ#h+h3?>*CJOJQJ^JaJ#h+hLT5CJOJQJ^JaJ h+hLTCJOJQJ^JaJ#h+h5>*CJOJQJ^JaJ<q8mtggttttttg h$Ifgd)? 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