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:  

*Expected Start Date:   / /     *Expected End Date:   / /

5. Scanning


*Tracer 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