University of Wisconsin-Madison
The Waisman Brain Imaging Core

Time Request Form for Psychophysiology Projects

Psychophysiology facility fee is $30 per hour.

Before you request time, you must have filled in and submitted the Acquisition Strategy Request Form form.

Principal Investigator:

Person to contact with questions (if other than PI):



PI Email:

Contact Email:

Contact Phone:

Project Title:

Project Funding Source:

Project Grant Number (from Funding Source):

Project Funding Period:

Approved HSC Protocol Number and Expiration Date:

UW Madison Fund and Account Number:

UW Madison UDDS:

Waisman Center Billing Account Name:

Total Number of approved subjects for study:

Number of
Normal Controls:
Age Range:
of Patients:
Diagnosis: Age Range:

Proposed start date:

Proposed end date for data collection:

Number of session hours requested per week:

Length of Data Collection Session (including setup and breakdown): hours

Name(s) of person(s) who will run ALL sessions: (Note: There will not be a technician present!)

This person has been trained: (Note: You will be required to pass a training!)
      Yes       No

Special subject care needs:

Imaging and equipment needs:

Personnel. List all key personnel and their role on project:

Plans for data analysis.

I have already submitted my Acquisition Strategy Request form: Yes      No

Please send the following to BI Requests, so that time in the psychophysiology room may be scheduled.

For Human Subjects:

  1. Human Subjects Research Protocol
  2. IRB approval letter
  3. Consent Form(s)

Last updated: August 2, 2012