{"id":4129,"date":"2016-12-29T14:55:04","date_gmt":"2016-12-29T19:55:04","guid":{"rendered":"https:\/\/med.virginia.edu\/radiology\/?page_id=4129"},"modified":"2016-12-29T14:55:04","modified_gmt":"2016-12-29T19:55:04","slug":"nuclear-medicine-imaging-for-research-form-revised-draft","status":"publish","type":"page","link":"https:\/\/med.virginia.edu\/radiology\/nuclear-medicine-imaging-for-research-form-revised-draft\/","title":{"rendered":"Nuclear Medicine Imaging for Research Form\u2014REVISED 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_16' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">NUCLEAR MEDICINE 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_16'  action='\/radiology\/wp-json\/wp\/v2\/pages\/4129' data-formid='16' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LebeGYrAAAAAP5BASaCDpdLeg5wBa6YY3ZS7nZh' data-tabindex='0'><input id=\"input_92cb528243734bfe6ab40e29c8c30ac4\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_92cb528243734bfe6ab40e29c8c30ac4\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_16' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_16_55\" 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_16_55'>Comments<\/label><div class='ginput_container'><input name='input_55' id='input_16_55' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_16_55'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_16_50\" class=\"gfield gfield--type-text gfield--input-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_16_50'>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_50' id='input_16_50' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_43\" class=\"gfield gfield--type-text gfield--input-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_16_43'>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_43' id='input_16_43' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_3\" class=\"gfield gfield--type-text gfield--input-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_16_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_16_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_5\" class=\"gfield gfield--type-text gfield--input-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_16_5'>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_5' id='input_16_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_34\" class=\"gfield gfield--type-email gfield--input-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_16_34'>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_34' id='input_16_34' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_16_6\" class=\"gfield gfield--type-text gfield--input-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_16_6'>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_6' id='input_16_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_7\" class=\"gfield gfield--type-text gfield--input-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_16_7'>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_7' id='input_16_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_8\" class=\"gfield gfield--type-textarea gfield--input-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_16_8'>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_8' id='input_16_8' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_16_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >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_16_16'>Do NOT check if being done for clinical care. For studies involving multiple types of nuclear medicine scans, fill out a separate form for each.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_16'>\n\t\t\t<div class='gchoice gchoice_16_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Nuclear Medicine Imaging'  id='choice_16_16_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_16_16\"   \/>\n\t\t\t\t\t<label for='choice_16_16_0' id='label_16_16_0' class='gform-field-label gform-field-label--type-inline'>Nuclear Medicine Imaging<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Off-Label or Non-FDA Approved Imaging'  id='choice_16_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_16_1' id='label_16_16_1' class='gform-field-label gform-field-label--type-inline'>Off-Label or Non-FDA Approved Imaging<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_10\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Nuclear Medicine Imaging<\/h3><div class='gsection_description' id='gfield_description_16_10'>Use section other section for Off-Label or Non-FDA approved usage.<\/div><\/div><fieldset id=\"field_16_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Is the radiopharmaceutical FDA approved for intended use?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_16_11'><div class='gchoice gchoice_16_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Yes'  id='choice_16_11_1'   aria-describedby=\"gfield_description_16_11\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_16_11_1' id='label_16_11_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='No'  id='choice_16_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_11_2' id='label_16_11_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_16_11'>If you answered No, go back and check the box for Off-Label or Non-FDA Approved Imaging in the question above.<\/div><\/fieldset><div id=\"field_16_12\" class=\"gfield gfield--type-text gfield--input-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_16_12'>Indicate radiopharmaceutical being used<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_16_12' type='text' value='' class='medium'  aria-describedby=\"gfield_description_16_12\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_16_12'>e.g. 99mTc- Sestamibi<\/div><\/div><div id=\"field_16_13\" class=\"gfield gfield--type-text gfield--input-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_16_13'>Scan Type<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_16_13' type='text' value='' class='medium'  aria-describedby=\"gfield_description_16_13\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_16_13'>e.g. MUGA, Bone Scan<\/div><\/div><div id=\"field_16_45\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Scan 1<\/h3><div class='gsection_description' id='gfield_description_16_45'>Rest and Stress scans are considered 2 separate scans. MUGA scans typicaaly use 30 mCi\/scan. Not all procedures will have multiple scan protocols - leave \"Scan 2\" blank for these types of procedures. Enter N\/A for number of scans if end point not known and indicate the frequency in the section below.<\/div><\/div><div id=\"field_16_36\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_36'>Number of Scans: Scan 1<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_16_36' type='text' value='' class='medium'    placeholder='Number of Scans'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_35\" class=\"gfield gfield--type-text gfield--input-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_16_35'>Injected Activity: Scan 1<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_16_35' type='text' value='' class='medium'    placeholder='mCi\/scan'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_44\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Scan 2<\/h3><div class='gsection_description' id='gfield_description_16_44'>Not all procedures will have multiple scan protocols - leave this question blank for these types of procedures. Enter N\/A for number of scans if end point not known and indicate the frequency in the box below.<\/div><\/div><div id=\"field_16_37\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_37'>Number of Scans: Scan 2<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_16_37' type='text' value='' class='medium'    placeholder='Number of Scans'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_38\" class=\"gfield gfield--type-text gfield--input-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_16_38'>Injected Activity: Scan 2<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_16_38' type='text' value='' class='medium'    placeholder='mCi\/scan'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_46\" class=\"gfield gfield--type-section gfield--input-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_16_20\" class=\"gfield gfield--type-text gfield--input-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_16_20'>Frequency or time points that these scans will be performed for research<\/label><div class='gfield_description' id='gfield_description_16_20'>Leave blank if total number is indicated above<\/div><div class='ginput_container ginput_container_text'><input name='input_20' id='input_16_20' type='text' value='' class='medium'  aria-describedby=\"gfield_description_16_20\"    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_16_14\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Is this a PET\/CT imaging study?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_16_14'><div class='gchoice gchoice_16_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Yes'  id='choice_16_14_1'   aria-describedby=\"gfield_description_16_14\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_16_14_1' id='label_16_14_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='No'  id='choice_16_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_14_2' id='label_16_14_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_16_14'>A CT scan is performed with ALL PET scans<\/div><\/fieldset><div id=\"field_16_29\" class=\"gfield gfield--type-text gfield--input-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_16_29'>If yes, indicate the anatomy being imaged w\/ CT<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_16_29' type='text' value='' class='medium'  aria-describedby=\"gfield_description_16_29\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_16_29'>e.g. abdomen, head, whole body<\/div><\/div><div id=\"field_16_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Off-Label or Non-FDA Approved Imaging<\/h3><\/div><div id=\"field_16_22\" class=\"gfield gfield--type-text gfield--input-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_16_22'>Indicate radiopharmaceutical being used:<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_16_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_23\" class=\"gfield gfield--type-text gfield--input-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_16_23'>IND #:<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_16_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Scan 1<\/h3><div class='gsection_description' id='gfield_description_16_47'>Not all procedures will have multiple scan protocols - leave \"Scan 2\" blank for these types of procedures. Enter N\/A for number of scans if end point not known and indicate the frequency in the box below.<\/div><\/div><div id=\"field_16_39\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_39'>Number of Scans: Scan 1<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_16_39' type='text' value='' class='medium'    placeholder='Number of Scans'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_40\" class=\"gfield gfield--type-text gfield--input-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_16_40'>Injected Activity: Scan 1<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_16_40' type='text' value='' class='medium'    placeholder='mCi\/scan'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_48\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Scan 2<\/h3><div class='gsection_description' id='gfield_description_16_48'>Not all procedures will have multiple scan protocols - leave this question blank for these types of procedures. Enter N\/A for number of scans if end point not known and indicate the frequency in the section below.<\/div><\/div><div id=\"field_16_41\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_41'>Number of Scans: Scan 2<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_16_41' type='text' value='' class='medium'    placeholder='Number of Scans'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_42\" class=\"gfield gfield--type-text gfield--input-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_16_42'>Injected Activity: Scan 2<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_16_42' type='text' value='' class='medium'    placeholder='mCi\/scan'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_49\" class=\"gfield gfield--type-section gfield--input-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_16_27\" class=\"gfield gfield--type-text gfield--input-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_16_27'>Frequency or time points that these scans will be performed for research<\/label><div class='gfield_description' id='gfield_description_16_27'>Leave blank if total number is indicated above<\/div><div class='ginput_container ginput_container_text'><input name='input_27' id='input_16_27' type='text' value='' class='medium'  aria-describedby=\"gfield_description_16_27\"    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_16_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Is this a PET\/CT imaging study?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_16_28'><div class='gchoice gchoice_16_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Yes'  id='choice_16_28_1'   aria-describedby=\"gfield_description_16_28\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_16_28_1' id='label_16_28_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='No'  id='choice_16_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_28_2' id='label_16_28_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_16_28'>A CT scan is performed with ALL PET scans<\/div><\/fieldset><div id=\"field_16_15\" class=\"gfield gfield--type-text gfield--input-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_16_15'>If yes, indicate the anatomy being imaged w\/ CT<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_16_15' type='text' value='' class='medium'  aria-describedby=\"gfield_description_16_15\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_16_15'>e.g. abdomen, head, whole body<\/div><\/div><div id=\"field_16_30\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_16_30'>For questions regarding Nuclear Medicine Procedures, contact Alfredo Lopez at x49364<\/div><\/div><div id=\"field_16_31\" class=\"gfield gfield--type-textarea gfield--input-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_16_31'>Additional Comments<\/label><div class='gfield_description' id='gfield_description_16_31'>If the 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_31' id='input_16_31' class='textarea medium'  aria-describedby=\"gfield_description_16_31\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_16_51\" class=\"gfield gfield--type-fileupload gfield--input-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_16_51'>Supporting Documents<\/label><div class='gfield_description' id='gfield_description_16_51'>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_16_51' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_16_51&quot;,&quot;container&quot;:&quot;gform_multifile_upload_16_51&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_16_51&quot;,&quot;filelist&quot;:&quot;gform_preview_16_51&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;:16,&quot;field_id&quot;:51,&quot;_gform_file_upload_nonce_16_51&quot;:&quot;939ba73f77&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_16_51&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_16_51' 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_16_51' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_16_51 gfield_description_16_51\"  >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_16_51'>Max. file size: 100 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_16_51'><\/ul> <div id='gform_preview_16_51' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_16_53\" class=\"gfield gfield--type-section gfield--input-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_16_52\" class=\"gfield gfield--type-text gfield--input-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_16_52'>Billing (PTAO# Required)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_16_52'>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 Nuclear Medicine AND X-ray forms, you will only be charged once. PLEASE ENTER PTAO# BELOW:<\/div><div class='ginput_container ginput_container_text'><input name='input_52' id='input_16_52' type='text' value='' class='small'  aria-describedby=\"gfield_description_16_52\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_54\" class=\"gfield gfield--type-section gfield--input-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_16_32\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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_16_32'><div class='gchoice gchoice_16_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' 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 Nuclear Medicine imaging.'  id='choice_16_32_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_1' id='label_16_32_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 Nuclear Medicine imaging.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_33\" class=\"gfield gfield--type-text gfield--input-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_16_33'>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_33' id='input_16_33' 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_16' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_16' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_16' id='gform_theme_16' 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*\/\n<\/script>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":80,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":"","_links_to":"","_links_to_target":""},"tags":[],"class_list":["post-4129","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Nuclear Medicine Imaging for Research Form\u2014REVISED DRAFT - Radiology and Medical Imaging<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/med.virginia.edu\/radiology\/nuclear-medicine-imaging-for-research-form-revised-draft\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" 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