X-Ray Imaging Research Form

Please Note: Do not add personnel from outside of UVA to the form. This form is to be completed by UVA study team members and is to indicate contact information for members within the UVA System.

IRB-HSR Submission #*

Sponsor Protocol #*

Sponsor*

Principal Investigator*

UVA Study Contact*

UVA Study Contact Email*

Study Coordinator (if different from UVA Study Contact listed above)

Study Coordinator Email

Title of Study*

Modalities/Procedures used for Research*

Check ALL that apply, do NOT check if being done for clinical care.

X-Ray
CT (Computed Tomography)
Fluoroscopy
Mammography

X-Ray

For questions regarding X-ray procedures, contact Laura Asbeil or Anthony Calise x 36736

Scan

Abdomen
Extremity (hand/foot)
Skull
Chest
Spine
Pelvis
Other

If "other" please explain:

If the scan involves a series of images, please specify series to be used:

Examples: chest-PA + lateral, spine-lumbar spine series

Total # of Scans to be performed for research

Enter N/A for # of scans if end point not known and indicate frequency below

Frequency or time points that these scans will be performed for research:

CT (Computed Tomography)

For questions regarding CT procedures, contact Lorie Hubbard x20519

Scan

Head
Neck
Sinus
Chest
Abdomen
Pelvis
Spine
Cardiac
Other

If "other" please explain:

Contrast

With
Without

Total # of Scans to be performed for research

Enter N/A for # of scans if end point not known and indicate frequency below

Frequency or time points that these scans will be performed for research:

Fluroscopy

For questions regarding Fluoroscopy procedures, contact Allen Goode at x42163

Additional minutes to be used:

# of CINE runs:

# DSA runs

# Single frame acquisitions:

Anatomy being imaged:

Mammography

For questions regarding Mammography procedures, contact Dawn Derenburger x42213

Scan

Standard 4 View
Other

If "other" please explain:

Total # of Scans to be performed for research

Enter N/A for # of scans if end point not known and indicate frequency below

Frequency or time points that these scans will be performed for research:

Additional Comments

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.

Supporting Documents

Drop files here or

Max. file size: 100 MB.

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.

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. Errors and/or omissions could result in significant delay of approved consent language.

PI initials typed*

X-RAY IMAGING FOR RESEARCH FORM

Please Note: Do not add personnel from outside of UVA to the form. This form is to be completed by UVA study team members and is to indicate contact information for members within the UVA System.

X-Ray

CT (Computed Tomography)

Fluroscopy

Mammography