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

Time Request Form for 3.0T MR Imaging Projects

Scanning fee is $425 per hour.

Principal Investigator:

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

Department:

Address:

Email address:

Phone:

Fax:

Project P.I.:

Overall P.I. of grant if a multi-project grant:

Project Title:

Project Funding Source:

Project Grant Number (from Funding Source):

Project Funding Period:

Approved HSC Protocol Number:

UW Madison Fund and Account Number:

UW Madison UDDS:

Waisman Center Billing Account Name:

Number of approved subjects for study:
# Normal Controls: Age range:
# Patients: Diagnosis: Age range:

Proposed start date:

Number of scanning hours requested per week (billed at $400/per hr):

Length of Scanning Protocol: hours

Preferred scanning days and times (check all that apply):
SunMonTueWedThuFriSat
6 am
7 am
8 am
9 am
10 am
11 am
12 noon
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm

Click one:
      I request scanner time with technician support
      I do not require technician support

Name of person who will run ALL scans:

Person named above received training from:

Special patient care, imaging or equipment needs:

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

For Human Subjects:

  1. Human Subjects Research Protocol
  2. IRB approval letter
  3. Consent Form(s) and
  4. Certification of Human Subjects Research Training (listing all key personnel)
  5. HIPAA authorization form
  6. A copy of the grant that is providing the funding for these scans

For Non-Human Subjects:

  1. Approved Animal Research Protocol(s)
  2. RARC approval letter
Last updated: August 8, 2006
Email: dmcole@wisc.edu