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Instructions: To Edit form, go to the “View” tab, then select “Edit” Complete the entire form and submit form to radiology-research@ and radiology-research@cumc.columbia.edu Provide a copy of protocol, research plan and imaging manual with this submission. Identify the protocol page numbers pertaining to the Radiology procedures FORMTEXT ????? Principal Investigator FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????Coordinator FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????Financial Administrator FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????Study Title FORMTEXT ?????Department initiating Study FORMTEXT ?????NIH or Industry FORMTEXT ?????Sponsor name FORMTEXT ?????Estimated number of subjects to be enrolled in study FORMTEXT ?????Estimated frequency of subject scanning FORMTEXT ?????Estimated start date FORMTEXT ?????Estimated end date FORMTEXT ?????IRB# (if not available provide to Radiology when obtained) FORMTEXT ?????Clinical Study Trial # (NCT # on ) FORMTEXT ?????Please choose all that are required:ProcedureContrastCPT Code(s) Location CostsProcedureCPTLocationNYP TechnicalCUMC ProfessionalCUMC 168thSt & 51st St CT FORMCHECKBOX 51st street FORMCHECKBOX 168th street FORMCHECKBOX CT Orbits FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX CT Face FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX CT Head/ Brain FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX Neck FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX CT Chest FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX CT Abdomen FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX CT Abd & Pelvis FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX CT Pelvis FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX CT upper extremity FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX CT lower extremity FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC ProcedureCPTLocationNYP TechnicalCUMC ProfessionalCUMC 168thSt & 51st St FORMCHECKBOX Cervical spine FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX Thoracic spine FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX Lumbar spine FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX W FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMCNUCLEAR MEDICINE and BONE DENSITY ProcedureCPTLocationNYP TechnicalCUMC ProfessionalCUMC 168thSt & 51st St FORMCHECKBOX Whole Body Bone Scan FORMCHECKBOX NYP FORMCHECKBOX MUGA FORMCHECKBOX NYP FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX NYP FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX NYP MRI FORMCHECKBOX 51st street FORMCHECKBOX 168th street FORMCHECKBOX Face, Neck, Orbits FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX MRI Brain FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX MRI Chest FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX MRI Abdomen FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX MRI Pelvis FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYP FORMCHECKBOX CUMC FORMCHECKBOX MRI Breast FORMCHECKBOX W’O FORMCHECKBOX W/W’O FORMCHECKBOX NYPX-RAYS1 view2 viewCPTLocationNYP TechnicalCUMC ProfessionalCUMC 168thSt & 51st St FORMCHECKBOX Chest FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NYP FORMCHECKBOX Skeletal survey FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NYP FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NYPULTRASOUND FORMCHECKBOX Abdomen FORMCHECKBOX complete FORMCHECKBOX limited FORMCHECKBOX NYP FORMCHECKBOX Breast FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX NYP FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX NYPPET Scan and PET/CTProcedureCPTLocationNYP TechnicalCUMC ProfessionalCUMC PET Center 168thSt FORMCHECKBOX FDG, if required, per dose FORMCHECKBOX CUMC FORMCHECKBOX Other tracer: FORMTEXT ????? FORMCHECKBOX CUMC FORMCHECKBOX Brain PET FORMCHECKBOX CUMC FORMCHECKBOX PET Whole Body Scan (head to toe) NOT SUITABLE FOR RECIST FORMCHECKBOX CUMC FORMCHECKBOX PET/CT Skull to mid-thigh NOT SUITABLE FOR RECIST FORMCHECKBOX CUMC FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX CUMC FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX CUMC BIOPSY AND GUIDANCE FORMCHECKBOX 51st street FORMCHECKBOX 168th street NYPProcedureCPTLocationNYP TechnicalCUMC ProfessionalCUMC 51st Street FORMCHECKBOX CT guidance FORMCHECKBOX NYP FORMCHECKBOX US guidance FORMCHECKBOX NYP FORMCHECKBOX Biopsy, location may vary (eg liver) FORMCHECKBOX NYP FORMCHECKBOX FORMTEXT Renal biopsy FORMCHECKBOX NYP FORMCHECKBOX FORMTEXT Lung biopsy FORMCHECKBOX NYPNot performed FORMCHECKBOX Lymph node –core needle or excisional LN biopsy FORMCHECKBOX NYP FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX NYPPHANTOM SCANS and SET-UP SCANSNotes:Phantom test scans: the sponsor must provide the phantom object and the cost of the exam will be charged. ?Phantom Scan Protocol is required for review.Phantom Scan ?Frequency _______Special Calibrated Device (Phantom) ? Frequency FORMTEXT ????? Human Volunteer ? Set –up ? (baseline) FORMTEXT ?????Please Note:?Human Volunteer scans: The cost of the exam will be charged if imaging is performed on a volunteer. ?Test scans on human volunteers require that the volunteer be consented under the study protocol.TUMOR ASSESSMENT READS FORMCHECKBOX RECIST FORMCHECKBOX CHESSON FORMCHECKBOX OTHER FORMTEXT ?????Data Transmission/ Transfer Cost FORMCHECKBOX de-identified CDs / FTP transfers Further Instructions and Notes from Dept. of Radiology Note not all may be required for your study For NIH / Foundation studies that require RASCAL-PT approval from RadiologyAt the time of Cost Estimate submission and Initial Budget review:for CUMC Radiology Dept approval - please add Rae Vaggfor NYP Radiology Dept approval – please add Kate SpazianiPrior to the start of the study:One month prior to first subject scan For NYP/ CHONY/ CUMC location scans: Email Directors/ contacts of the Radiological Centers for a Start-up meeting: IRB #, PI name, (updated) approved Protocol, Imaging guidelines / manual, IRB approval, JRSC packet and approval, chart stringNote: following the review of the imaging guidelines and protocol, a Research Protocol has to be built into the scanner by the Radiologist, hence the request for imaging protocol 1 month prior to first subject scan.PI Signature FORMTEXT ????? FORMTEXT ?????Date Signed FORMTEXT ?????Date submitted FORMTEXT ????? ................
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