Trial online version of Yale University PET Center Protocol Initiation Form - v 2
(author: edm, last edited 11/11//2011 8:50pm)
1. PI Information
*PI: *First name
*Last name
*Email:
*Phone: (
)
-
2. Protocol Information
*Protocol Title:
Protocol Short Name (generated in PET Center):
* At least one of the following is required for form submission:
HIC Number: #
IACUC Number: #
-
3. Personnel
Research Assistant:
Phone:
Email:
Scheduler:
Phone:
Email:
Personnel to participate at PET Center
Medical Staff to be provided by PI
phone
email
Nursing Staff to be provided by PI
phone
email
Vet Staff to be provided by PI
phone
email
4. Scans
*Number of Scans:
*Number of Scans per Subject:
*Time/Day Restrictions:
No Mondays; No Friday 13th
*Expected Start Date:
/
/
*Expected End Date:
/
/
5. Scanning
*Scanner(s):
HRRT (Hi Resolution Brain Scanner)
HR+ (Brain or Whole Body)
MCT (Brain or Whole Body with Hi Resolution CT)
FOCUS (Animal Scanner for Primates or Rodents)
MCT or HR+ (No Preference between these two)
HRRT or HR+ (No Preference between these two)
Any Human Scanner will suffice
Let Maria Decide
*Tracer Source:
Made by Yale PET Center
Purchased/Delivered by Outside Source
Metabolites
Arterial line
PK Samples
6. Billing
P T A E O
*PTAEO Number:
.
.
.
.
.
*Billing Contact Name:
Phone:
Email:
Split Charges Between Two Accounts
Second PTAEO Number:
.
.
.
.
.
Billing Notes:
7. Document Checklist
Please indicate which of the following is already on file with the PET Center (**required for imaging to begin)
**
YNHH Radiation Safety Committee Approval Letter (
human studies only
)
2915 Form delivered to YNHH RSC for submission to FDA (for human studies with > 31 subjects)
**
Yale University RSC Approval letter
**
Electronic copy of Approved Protocol
**
Electronic copy of HIC Approval Letter (
human studies only
)
**
Electronic copy of Approved Consents (
human studies only
)
8. Funding Source
Funding Agency:
Funding Mechanism:
9. Submit Data to PET Center