Center for Imaging Research

Research Study Information Form

For Human Studies:

IRB #   Governing IRB  MCW   OR CHW

CTSI # (if applicable)

For Animal Studies:

AUA #

For All Studies:

Name of Study

Latest Approval Date               

Projected End Date

(A copy of your current approval letter and stamped consent form must be submitted.  They may be e-mailed, faxed or mailed.)

Grant Information:

Grant Source (NIH, Foundation, Intramural, etc.)

Grant #

Annual Direct Costs

Principal Investigator Information

Name Title MD PhD Both

Phone # Email

Mailing Address  

Co-Investigator Information

Name Title MD PhD Both

Phone # Email

Mailing Address  

Billing Information

Primary Billing

(This is where invoices will initially be sent. It is often the PI, CTSI or the PI's administrator)

Administrator Name

Phone # Email

Mailing Address   

Secondary Billing

(This is where the invoices will be sent if they are returned unpaid by the primary billing contact.)

Administrator Name

Phone # Email

Mailing Address