Research Study Information Form

Research Study Information Form

Investigators must complete this form prior to using the CIR scanners. Please allow five business days for this form to be processed.
Please contact Kathleen Yin with questions related to human research or Matt Runquist with questions related to animal research.

Study Information

Principal Investigator

   Check if PI is responsible for payment

    Name 

    Department  

    Institution 

    Email 

Co-Principal Investigator

    Check if Co-PI is responsible for payment

    Name 

    Department  

    Institution  

    Email 

Study Coordinator

    Name 

    Department  

    Institution

    Email 

    Phone No. 


Protocol No.  

Study Title 

Regulatory Authority:   MCW IRB      CHW IRB       MCW IACUC       NA, specify reason in Comments section below. 

IRB/IACUC Approval Period (dd-mm-yyyy)   to 

If human research, upload current stamped consent form (or IRB approval letter)  

If human research, CTSI No. (type NA if this field is not applicable) 


Scanner 

Upload research MRI Safety Committee approval letter  

Note that investigators and their team members must obtain research MRI Safety Training prior to scanner use.


Billing Information

Invoices will be emailed to the administrator.

Administrator

    Name  

    Department  

    Institution 

    Email  

    Phone No.  


Funding Information

Funding Source A (NIH, Foundation, Intramural, Soref, etc.) 

    Funding Account No. 

    Start Date (dd-mm-yyyy)  / End Date (dd-mm-yyyy) 

    Annual Direct Costs $


Funding Source B (NIH, Foundation, Intramural, Soref, etc.) 

    Funding Account No. 

    Start Date (dd-mm-yyyy)  / End Date (dd-mm-yyyy) 

    Annual Direct Costs $


Funding Source C (NIH, Foundation, Intramural, Soref, etc.) 

    Funding Account No. 

    Start Date (dd-mm-yyyy)  / End Date (dd-mm-yyyy) 

    Annual Direct Costs $


Funding Source D (NIH, Foundation, Intramural, Soref, etc.) 

    Funding Account No. 

    Start Date (dd-mm-yyyy)  / End Date (dd-mm-yyyy) 

    Annual Direct Costs $


Funding Source E (NIH, Foundation, Intramural, Soref, etc.) 

    Funding Account No. 

    Start Date (dd-mm-yyyy)  / End Date (dd-mm-yyyy) 

    Annual Direct Costs $


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