Project Title:

Project Funding Source:

Project Grant Number (from Funding Source):

Project Funding Period:

Approved RARC Protocol Number:

Yes, I have a completed and approved Form 99A: Application for Use of Radionuclides in Vertebrate Animals
        (see http://www.fpm.wisc.edu/safety/radiation/form99a.pdf)

UW Madison Fund and Account Number:

UW Madison UDDS:

Waisman Center Billing Account Name:

Species:

Number of approved animals for study:

Proposed start date:

Number of scanning sessions requested per week:

Preferred scanning day(s):
Mon   Tue   Wed   Thu   Fri   Any Day (no preference)

Name of person who will run ALL scans and be responsible for animal supervision during scan:

Special animal care, imaging or equipment needs:

Name of radiotracer and supply source:

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

Plans for data analysis. State personnel and resources available to fund analysis of these data:

Please contact Alex Converse (phone: 265-6604) prior to scanning to plan program, or if you need technical information.

Please send the following to Donna Cole, T221 Waisman Center, so that scanning time may be scheduled.

For Non-Human Subjects:

1. Approved Animal Research Protocol(s)
2. RARC approval letter