Boston
Medical Center
Echocardiography Research Study Form
Request Initiated by:
Full Name:
Email:
Title of Study:
Principal Investigator
Name:
Email:
Office:
Cell or Mobile:
Fax:
Pager:
Site Coordinator
Name:
Email:
Office:
Cell or Mobile:
Fax:
Pager:
Department:
Please select...
Alzheimers Disease Center
Amyloidosis Center
Anatomy & Neurobiology
Anesthesiology
Arthritis Center
Biochemistry
Biomedical Mass Spectrometry, Center for
CReM - Regenerative Medicine, Center for
Cancer Care Center
CTSI
Dermatology
Emergency Medicine
Epidemiology Bioscience
Family Medicine
Framingham Heart Study
Gastrointestinal Surgery
Medical Education
Medicine
Microbiology
National Emerging Infectious Disease Lab
Neurology
Neurosurgery
Obstetrics / Gynecology
Opthamology
Oral and Maxillofacial Surgery
Orthopedic Surgery
Otolaryngology - Head and Neck Surgery
Pathology and Laboratory Medicine
Pediatrics
Pharmacology and Experimental Therapeutics
Physiology and Biophysics
Proteomics
Psychiatry
Pulmonary Center
Radiation Oncology
Radiology
Rehabilitation Medicine
Slone Epidemiology Center
Surgery
Urology
Whitaker Cardiovascular Institute
Division:
Please select...
Amyloid Research and Training Program
Biomedical Genetics
Calcium Signaling Unit
Cardiology
Clinical Epi Research and Training Center
Computational Biomedicine
Endocrinology, Diabetes and Nutrition
Gastroenterology
General Internal Medicine
Geriatrics
Hematology and Medical Oncology
Infectious Diseases
Medicine
Nephrology
Preventive Medicine and Epidemiology
Pulmonary, Allergy and Critical Care
Rheumatology
Vascular Biology
Vitamin D Lab
Division:
Please select...
Stroke
Division:
Please select...
General Obstetrics
General Gynecology
Gynecological Oncology
Maternal-Fetal Medicine
Division:
Please select...
Orthopedic Surgery
Pediatric Orthopedic Surgery
Division:
Please select...
Adolescent Clinic
General
Infectious Diseases
Division:
Please select...
Acute Care and Trauma Surgery
Cardiac Surgery
Colon and Rectal Surgery
General Surgery
Pediatric Surgery
Plastic and Reconstructive Surgery
Podiatry
Surgical Critical Care
Surgical Endocrinology
Surgical Oncology
Thoracic Surgery
Transplant Surgery
Vascular and Endovascular Surgery
Address:
Department Administrator
Name:
Email:
Phone:
Fax:
Pager:
Funding entity:
Industry
Federal
Foundation
Investigator
Collaboration/ Jointly
Other
Please upload Protocol, MCA and Budget
Protocol
MCA (if available)
Budget (For grants funded study)
Sponsor/Corporation/NIH:
Phase:
Is study Local IRB or Central IRB?
Please select...
Local-BUSM
Central-Advarra
Central-Other
Central-WIRB
Is the study approved?
Yes
No
Is study Budget approved?
Yes
No
Multi-center?
Yes
No
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:
Yes
No
Please explain:
Number of Echocardiography imaging requested:
Expected frequency of Echocardiography imaging:
Is professional read by Cardiology team needed for Echocardiography imaging?
Yes
No
How images will be transmitted or stored?
Burn to DVD
Electronic transmission
Other
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