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

Time Request Form for PET Imaging Projects

Scanning fee is $538 per hour. Tech time is $50 per hour.
Radiotracer chemistry and data analysis can be supplied for an additional charge.

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 HSC Protocol Number:

Yes, I have a completed and approved Form 99A: Application for Use of Radionuclides in Vertebrate Animals
       

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:

Length of Scanning Protocol: hours

Preferred scanning days/times (check all that apply):
     Monday:
          mornings (8 am - noon)           afternoons (noon - 5 pm)           evenings (5 pm to 9 pm)
    Tuesday:
          mornings (8 am - noon)           afternoons (noon - 5 pm)           evenings (5 pm to 9 pm)
    Wednesday:
          mornings (8 am - noon)           afternoons (noon - 5 pm)           evenings (5 pm to 9 pm)
    Thursday:
          mornings (8 am - noon)           afternoons (noon - 5 pm)           evenings (5 pm to 9 pm)
    Friday:
          mornings (8 am - noon)           afternoons (noon - 5 pm)           evenings (5 pm to 9 pm)
    Saturday:
          mornings (8 am - noon)           afternoons (noon - 5 pm)           evenings (5 pm to 9 pm)
    Sunday:
          mornings (8 am - noon)           afternoons (noon - 5 pm)           evenings (5 pm to 9 pm)

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

Name of person who will run ALL scans:

Person named above received training from:

Special patient care, imaging or equipment needs:

Radiotracer supply source:

Supervising physician:

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 Brad Christian ( or 608-890-0750) if you need technical information.

Please send the following to BI Requests, 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: February 3, 2014
Email: bi_requests@lists.wisc.edu