University of Wisconsin-Madison
The Waisman Laboratory for Brain Imaging and Behavior

Time Request Form for Micro PET Imaging Projects

Scanning fees:

Harlow | Focus220 : $475 per hour without radiotracer
Waisman I P4 : $400 per hour without radiotracer

 

Principal Investigator:

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

Department:

Address:

Email address:

Phone:

Fax:

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 BI Requests, so that scanning time may be scheduled.

For Non-Human Subjects:

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

Last updated: April 16, 2013
Email: bi_requests@lists.wisc.edu