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:

Does your project require study specific imaging parameters/guidelines?:

yesno

In what cycles? Will it be monthly?

Please upload Imaging Guidelines:

Do these scans need Contrast?:

YesNo

Please select one of the following:

IV ContrastOral ContrastOral Contrast & IV Contrast

Do these studies need Clinical Reads?:

yesno

Do these studies need Case Report Forms (CRF's):

yesno

Will CD's/DVD's need to be burned/ Anonymized/ De-Identified/ Relabled with specific information from sponsor?:

yesno

How many?