Title of Study:

Department:

Division:

Address:

Sponsor/Corporation/NIH:

Phase:

Is study Local IRB or Central IRB?

Is the study approved?

YesNo

Is study Budget approved?

YesNo

Multi-center?

YesNo

Study Name:

BUMC IRB#:

Central IRB#:

BU Internal Order Number:

BMC Research Posting Project Number:

Is any part of this study being handled by the GCRC:

YesNo

Please explain:

Number of Echocardiography imaging requested:

Expected frequency of Echocardiography imaging:

Is professional read by Cardiology team needed for Echocardiography imaging?

YesNo

How images will be transmitted or stored?

Burn to DVDElectronic transmissionOther

If yes, how many?

You will be responsible for labeling the CD/DVD - provide sample of how you will label:

If selects "Other", please specify:

Number of patients expected to be enrolled at this site:

Expected start date

Duration of the study