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 |BODY PART(S) |
|Magnet Strength: 3T 1.5T |Head/Brain Neck Chest Abdomen Pelvis |
|Contrast: Without Without & With |Musculoskeletal: |
|MR Spectroscopy MR Angiogram fMRI (brain) |Spine: Cervical Thoracic Lumbar Sacrum |
|MR Perfusion DCE MR Perfusion ASL MR DTI |Organ/System: Esophagus Stomach Liver Kidney |
|Indication: Frequency: |Other: |
| |Lymphatics: |
|CT Scan |Vascular System: Venous Arterial |
|Contrast: With Without Without & With |Vessels: |
|CT Angiogram CT Perfusion CT Myelogram | |
|Indication: Frequency: | |
| 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: RadClinicalTrials@URMC.Rochester.edu
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