Principal Investigator:

Person to contact with questions (if other than PI):

Department:

Address:

Email address:

Phone:

Fax:

Project Title:

Project Funding Source:

Project Grant Number (from Funding Source):

Project Funding Period:

Approved HSC Protocol Number:

UW Madison Fund and Account Number:

UW Madison UDDS:

Waisman Center Billing Account Name:

Number of approved subjects for study:

# Normal Controls:		Age range:
# Patients:		Diagnosis:		Age range:

Proposed start date:

Number of scanning hours requested per week:

Length of Scanning Protocol: hours

Preferred scanning days/times (check all that apply):
      Friday:
          mornings (8 am - noon)           afternoons (noon - 5 pm)           evenings (5 pm to 9 pm)
      Saturday:
          mornings (8 am - noon)           afternoons (noon - 5 pm)           evenings (5 pm to 9 pm)
      Sunday:
          mornings (8 am - noon)           afternoons (noon - 5 pm)           evenings (5 pm to 9 pm)

Click one:
      I request scanner time with technologist support
      I do not require technologist support

Name of person who will run ALL scans:

Person named above received training from:

Special patient care, imaging or equipment needs:

Radiotracer supply source:

Supervising physician:

Personnel. List all key personnel and their role on project:

Plans for data analysis. State personnel and resources available to fund analysis of these data:

Please contact Brad Christian ( or 608-890-0750) or Terry Oakes ( or 608-265-6610) if you need technical information.

Please send the following to Donna Cole, T221 Waisman Center, so that scanning time may be scheduled.

For Human Subjects:

1. Human Subjects Research Protocol
2. IRB approval letter
3. Consent Form(s) and
4. Certification of Human Subjects Research Training (listing all key personnel)
5. HIPAA authorization form
6. A copy of the grant that is providing the funding for these scans

For Non-Human Subjects:

1. Approved Animal Research Protocol(s)
2. RARC approval letter