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FACE PAGE
FACILITIES USE APPLICATION
Center for Advanced Imaging
Department of Radiology
Principal Investigator: _____________________________________
Project Title: _______________________________________________________________________________
Department: _________________________ P.O. Box: __________ Phone: ________________
Facility Requested (Check One):
Top of Form
PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 1.5T MRI PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 3T MRI PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 PET PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 ERP/TMS
Bottom of Form
If this is a PET project, what radiopharmaceuticals are needed?__________________________
Proposed start date: ___________________ Proposed end date: ___________________
Number of subjects included in study ______ Total amount of facility time requested (hrs)? ____________
Are all the members of your team who will enter the research facility HIPAA certified? PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 Yes PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 No
Does the project involve human subjects? PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 Yes PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 No
If yes, provide the IRB Number: _____________ (Attach copy of approved protocol and consent form)
If yes, will the subjects be hospitalized? PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 Yes PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 No
Does the project involve animals? PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 Yes PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 No
If yes, provide the ACUC Number: _____________ (Attach copy of approved protocol)
Does the project involve the use of hazardous materials? PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 Yes PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 No
If yes, provide the names of the materials. _______________________________________
Is the project funded? PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 Yes PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 No
If yes, what is the funding source? ___________________________________
If no, is this a pilot project for subsequent submission of a grant application? PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 Yes PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 No
Is a technologists assistance necessary to operate the equipment? PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 Yes PRIVATE "" MACROBUTTON HTMLDirect EMBED Word.Picture.8 No
If no, list the name of person who will operate the equipment? ______________________________________
List all personnel who will be involved in the acquisition of data and when they have attended the appropriate safety training:
Name WVU Training Date Name WVU Training Date
Name WVU Training Date Name WVU Training Date
Name WVU Training Date Name WVU Training Date
On following pages please provide the requested information in the space allotted:
Hypothesis: What question is being asked? Briefly state the goal(s) of the project.
Background: Briefly state the relevance and importance of the project. In addition, briefly review the
work others have performed in this area (supply relevant references and three keywords).
Background Continued
Preliminary Data (optional):
Preliminary Data Continued
Methods: Describe the experimental protocol in detail. Please provide specific descriptions of where the resulting data will be stored and how the data will be analyzed. Who will perform the data analysis?
Methods Continued
Investigators: Describe the experience of the principal investigator and other key members of the project in acquiring and analyzing the data.
Project Number (Do not write in this space): ________________
PAGE 1
Revised 7/29/04
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