STUDY REQUEST FORM

To request time on the scanner, please complete the following form. We will attempt to schedule you within 2 weeks. The PI and contact person will be notified by email of the scheduled date and time. The appointment will be posted on the Schedule accessed from the Imaging Facility Homepage. Please note that it is the policy of the facility that investigators will be responsible for the care of their animals throughout the procedure. If you need to postpone the appointment, contact Doug Rowland(see below) at least 48 hr. prior to the scheduled time so that we can attempt to use the appointment for another investigator. If less than 48 hr. notice is given and another investigator cannot use it, you will be recharged for your appointment time. For Monday and Tuesday appointments, postponement cutoff days are Thursday and Friday, respectively.

All fields except those marked with an asterisk(*) are required.

PRINCIPAL INVESTIGATOR

First Name
Last Name
Email
Phone (xxx-xxx-xxxx)
*Are you a member of the UCDMC Cancer Center	Yes No

CONTACT PERSON

First Name
Last Name
Email
Phone (xxx-xxx-xxxx)

PROJECT INFORMATION

Title of Project:

Disease Model:	Intervention:
		Ctrl+<click> on PC to select multiple items for these fields. Option+<click> on Macintosh

Preferred Dates:

Type of Imaging:

PET MRI CT US Xenogen

Animal Use/Care Protocol#	AU/C Expire Date: (xx/xxxx)	Animal Species:

Recharge #	Funding End Date: (xx/xxxx)

Do gloves and other materials that contact animal or its body fluids need to be disposed as 'red bag' medical waste?

Yes No

*Number of animals to be scanned for project:

*Is this a longitudinal study?

Yes No

*Repeat scans at what timepoints?

Describe very briefly the objectives and procedures as related to the proposed imaging:

Image requirements: Describe what you want to image. Are single images or images taken at specified time intervals required per scanning session?

Data requirements: Indicate whether you need images only or whether you require data analysis. If the latter, describe your requirements.

Additional comments or special needs:

PET SCAN ONLY

If requesting PET scans, please provide the following:

RUA #	Next RUA Renewal (xx/xxxx)	Contrast Agent

If you are requesting a PET scan and you will not bring radioactive animals into or out of the facility, you may be able to conduct your study within the framework of the Center's RUA, in which case you do not need to provide an RUA number or renewal date.

Send copies of your approved Animal Use and Care Protocol and Radiation Use Authorization to Doug Rowland (djrowland@ucdavis.edu, Department of Biomedical Engineering.

By pressing the "Submit" button below, the person named as Principal Investigator signs to the authenticity of the information on this form. For questions, contact Doug Rowland (djrowland@ucdavis.edu; 530-754-8960).

(Please press only once, a copy of your request will be emailed to you)

STUDY REQUEST FORM

PRINCIPAL INVESTIGATOR

CONTACT PERSON

PROJECT INFORMATION

PET SCAN ONLY