{"id":4125,"date":"2016-12-28T11:21:55","date_gmt":"2016-12-28T16:21:55","guid":{"rendered":"https:\/\/med.virginia.edu\/radiology\/?page_id=4125"},"modified":"2016-12-28T11:23:13","modified_gmt":"2016-12-28T16:23:13","slug":"x-ray-imaging-for-research-form-revised-draft","status":"publish","type":"page","link":"https:\/\/med.virginia.edu\/radiology\/x-ray-imaging-for-research-form-revised-draft\/","title":{"rendered":"X-Ray Imaging for Research Form-REVISED DRAFT"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_15' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">X-RAY IMAGING FOR RESEARCH FORM - Copy 1<\/h2>\n                            <p class='gform_description'>Please note - this form is your communication with the HIRE committee. Errors and\/or omissions could result in significant delay of approved consent language. Please allow a minimum of 2 weeks processing time for your trial.<\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_15'  action='\/radiology\/wp-json\/wp\/v2\/pages\/4125' data-formid='15' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LebeGYrAAAAAP5BASaCDpdLeg5wBa6YY3ZS7nZh' data-tabindex='0'><input id=\"input_4c80892ff0f822fe0a44d9d3abb0470e\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_4c80892ff0f822fe0a44d9d3abb0470e\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_15' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_15_44\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_44'>Facebook<\/label><div class='ginput_container'><input name='input_44' id='input_15_44' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_15_44'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_15_39\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_39'>IRB-HSR Submission #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_15_39' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_38\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_38'>Sponsor Protocol #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_15_38' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_3\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_3'>Sponsor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_15_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_4\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_4'>Study Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_15_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_37\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_37'>Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_37' id='input_15_37' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_15_5\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_5'>Principal Investigator<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_15_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_6\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_6'>Study Coordinator<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_15_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_7\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_7'>Title of Study<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_7' id='input_15_7' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_15_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Modalities\/Procedures used for Research<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_15_9'>Check ALL that apply, do NOT check if being done for clinical care.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_9'><div class='gchoice gchoice_15_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='X-Ray'  id='choice_15_9_1'   aria-describedby=\"gfield_description_15_9\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_15_9_1' id='label_15_9_1' class='gform-field-label gform-field-label--type-inline'>X-Ray<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='CT (Computed Tomography)'  id='choice_15_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_9_2' id='label_15_9_2' class='gform-field-label gform-field-label--type-inline'>CT (Computed Tomography)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Fluoroscopy'  id='choice_15_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_9_3' id='label_15_9_3' class='gform-field-label gform-field-label--type-inline'>Fluoroscopy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Mammography'  id='choice_15_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_9_4' id='label_15_9_4' class='gform-field-label gform-field-label--type-inline'>Mammography<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_10\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">X-Ray<\/h3><div class='gsection_description' id='gfield_description_15_10'>For questions regarding X-ray procedures, contact Laura Asbeil or Anthony Calise x 36736<\/div><\/div><fieldset id=\"field_15_11\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Scan<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_11'><div class='gchoice gchoice_15_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Abdomen'  id='choice_15_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_11_1' id='label_15_11_1' class='gform-field-label gform-field-label--type-inline'>Abdomen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='Extremity (hand\/foot)'  id='choice_15_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_11_2' id='label_15_11_2' class='gform-field-label gform-field-label--type-inline'>Extremity (hand\/foot)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='Skull'  id='choice_15_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_11_3' id='label_15_11_3' class='gform-field-label gform-field-label--type-inline'>Skull<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.4' type='checkbox'  value='Chest'  id='choice_15_11_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_11_4' id='label_15_11_4' class='gform-field-label gform-field-label--type-inline'>Chest<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_11_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.5' type='checkbox'  value='Spine'  id='choice_15_11_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_11_5' id='label_15_11_5' class='gform-field-label gform-field-label--type-inline'>Spine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_11_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.6' type='checkbox'  value='Pelvis'  id='choice_15_11_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_11_6' id='label_15_11_6' class='gform-field-label gform-field-label--type-inline'>Pelvis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_11_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.7' type='checkbox'  value='Other'  id='choice_15_11_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_11_7' id='label_15_11_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_12'>If &quot;other&quot; please explain:<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_15_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_13\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_13'>If the scan involves a series of images, please specify series to be used:<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_15_13' type='text' value='' class='medium'  aria-describedby=\"gfield_description_15_13\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_15_13'>Examples: chest-PA + lateral, spine-lumbar spine series<\/div><\/div><div id=\"field_15_14\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_14'>Total # of Scans (per patient) to be performed for research<\/label><div class='gfield_description' id='gfield_description_15_14'>Enter N\/A for # of scans if end point not known and indicate frequency below<\/div><div class='ginput_container ginput_container_text'><input name='input_14' id='input_15_14' type='text' value='' class='medium'  aria-describedby=\"gfield_description_15_14\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_15\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_15'>Frequency or time points that these scans will be performed for research:<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_15_15' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_16\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">CT (Computed Tomography)<\/h3><div class='gsection_description' id='gfield_description_15_16'>For questions regarding CT procedures, contact Lorie Hubbard x20519<\/div><\/div><fieldset id=\"field_15_17\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Scan<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_17'><div class='gchoice gchoice_15_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Head'  id='choice_15_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_1' id='label_15_17_1' class='gform-field-label gform-field-label--type-inline'>Head<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Neck'  id='choice_15_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_2' id='label_15_17_2' class='gform-field-label gform-field-label--type-inline'>Neck<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Sinus'  id='choice_15_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_3' id='label_15_17_3' class='gform-field-label gform-field-label--type-inline'>Sinus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='Chest'  id='choice_15_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_4' id='label_15_17_4' class='gform-field-label gform-field-label--type-inline'>Chest<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Abdomen'  id='choice_15_17_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_5' id='label_15_17_5' class='gform-field-label gform-field-label--type-inline'>Abdomen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_17_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.6' type='checkbox'  value='Pelvis'  id='choice_15_17_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_6' id='label_15_17_6' class='gform-field-label gform-field-label--type-inline'>Pelvis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_17_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.7' type='checkbox'  value='Spine'  id='choice_15_17_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_7' id='label_15_17_7' class='gform-field-label gform-field-label--type-inline'>Spine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_17_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.8' type='checkbox'  value='Cardiac'  id='choice_15_17_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_8' id='label_15_17_8' class='gform-field-label gform-field-label--type-inline'>Cardiac<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_17_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.9' type='checkbox'  value='Other'  id='choice_15_17_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_9' id='label_15_17_9' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_18\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_18'>If &quot;other&quot; please explain:<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_15_18' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_19\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Contrast<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_19'>\n\t\t\t<div class='gchoice gchoice_15_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='With'  id='choice_15_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_19_0' id='label_15_19_0' class='gform-field-label gform-field-label--type-inline'>With<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_15_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Without'  id='choice_15_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_15_19_1' id='label_15_19_1' class='gform-field-label gform-field-label--type-inline'>Without<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_20\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_20'>Total # of Scans (per patient) to be performed for research<\/label><div class='gfield_description' id='gfield_description_15_20'>Enter N\/A for # of scans if end point not known and indicate frequency below<\/div><div class='ginput_container ginput_container_text'><input name='input_20' id='input_15_20' type='text' value='' class='medium'  aria-describedby=\"gfield_description_15_20\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_21\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_21'>Frequency or time points that these scans will be performed for research:<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_15_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_22\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Fluroscopy<\/h3><div class='gsection_description' id='gfield_description_15_22'>For questions regarding Fluoroscopy procedures, contact Allen Goode at x42163<\/div><\/div><div id=\"field_15_23\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_23'>Additional minutes to be used:<\/label><div class='ginput_container ginput_container_number'><input name='input_23' id='input_15_23' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_15_24\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_24'># of CINE runs:<\/label><div class='ginput_container ginput_container_number'><input name='input_24' id='input_15_24' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_15_25\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_25'># DSA runs<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_15_25' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_26\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_26'># Single frame acquisitions:<\/label><div class='ginput_container ginput_container_number'><input name='input_26' id='input_15_26' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_15_27\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_27'>Anatomy being imaged:<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_15_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_28\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Mammography<\/h3><div class='gsection_description' id='gfield_description_15_28'>For questions regarding Mammography procedures, contact Dawn Derenburger x42213<\/div><\/div><fieldset id=\"field_15_29\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Scan<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_29'><div class='gchoice gchoice_15_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Standard 4 View'  id='choice_15_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_29_1' id='label_15_29_1' class='gform-field-label gform-field-label--type-inline'>Standard 4 View<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Other'  id='choice_15_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_29_2' id='label_15_29_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_30\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_30'>If &quot;other&quot; please explain:<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_15_30' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_31\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_31'>Total # of Scans (per patient) to be performed for research<\/label><div class='gfield_description' id='gfield_description_15_31'>Enter N\/A for # of scans if end point not known and indicate frequency below<\/div><div class='ginput_container ginput_container_text'><input name='input_31' id='input_15_31' type='text' value='' class='medium'  aria-describedby=\"gfield_description_15_31\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_32\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_32'>Frequency or time points that these scans will be performed for research:<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_15_32' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_36\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_15_33\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_33'>Additional Comments<\/label><div class='gfield_description' id='gfield_description_15_33'>If trial does not have a clear end point, please specify what determines end of treatment. Also comment on what additional X-ray and\/or Nuclear Medicine based scans subjects will receive as standard of care.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_15_33' class='textarea medium'  aria-describedby=\"gfield_description_15_33\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_15_40\" class=\"gfield gfield--type-fileupload field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_15_40'>Supporting Documents<\/label><div class='gfield_description' id='gfield_description_15_40'>The majority of trials do NOT need supporting documents if the imaging for research purposes is simple. However, if your trial is sufficiently complicated, or you simply want us to have your protocol or other supporting documentation for clarity, upload those documents below.<\/div><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_15_40' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_15_40&quot;,&quot;container&quot;:&quot;gform_multifile_upload_15_40&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_15_40&quot;,&quot;filelist&quot;:&quot;gform_preview_15_40&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/med.virginia.edu\\\/radiology\\\/?gf_page=664dafdc95549f4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/med.virginia.edu\\\/radiology\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/med.virginia.edu\\\/radiology\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;104857600b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:15,&quot;field_id&quot;:40,&quot;_gform_file_upload_nonce_15_40&quot;:&quot;4593ed7fc5&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_15_40&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_15_40' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_15_40' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_15_40 gfield_description_15_40\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_15_40'>Max. file size: 100 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_15_40'><\/ul> <div id='gform_preview_15_40' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_15_42\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_15_41\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_41'>Billing (PTAO# Required)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_15_41'>For each trial submitted, the HIRE Committee now assesses a one-time charge of $350 to cover the hospital staff cost of dose calculation and the creation of consent language. If you submit both X-ray AND Nuclear Medicine forms, you will only be charged once. PLEASE ENTER PTAO# BELOW:<\/div><div class='ginput_container ginput_container_text'><input name='input_41' id='input_15_41' type='text' value='' class='small'  aria-describedby=\"gfield_description_15_41\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_43\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_15_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please Confirm<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_34'><div class='gchoice gchoice_15_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='The PI has considered alternatives to ionizing radiation imaging where possible and has worked to maximize the benefit\/risk ratio when using any x-ray imaging. Please note - this form is your communication with the HIRE committee.'  id='choice_15_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_34_1' id='label_15_34_1' class='gform-field-label gform-field-label--type-inline'>The PI has considered alternatives to ionizing radiation imaging where possible and has worked to maximize the benefit\/risk ratio when using any x-ray imaging. Please note - this form is your communication with the HIRE committee.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_35\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_35'>PI Initials (Typed)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_15_35' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_15' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit Form'  \/> \n            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