MRI Research Application Form

Specific Study Information

Project Title:*

Study Nickname*

(limited to 8 characters or less)

Principle Investigator*

First Last

Contact Person (if other than the PI):

First Last

Department*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Cell Phone*

Email*

Project Funding Source*

Project Grant Number (from Funding Source)*

Project Funding Period (starting date)*

MM

DD

YYYY

Project Funding Period (ending date)*

MM

DD

YYYY

Overall PI of Grant, if a Multi-Grant Project*

Funding Contact Person*

UW Madison Fund and Account Number*

UW Madison UDDS*

Is Project Human or Animal Research?*

Human
Animal

Proposed Start Date*

Please list all personnel, their contact information, and specify their role on this project:*

Please list any specific patient care, imaging, or equipment needs:*

MRI Scan Session Information:

Length of Individual Scan Session in Hours:*

Approximate Scanning Hours Requested per Week:*

Preferred Scanning Days and Times, if Available:*

The Lane Lab MRI is available for Research scanning Monday through Friday from 1:00 p.m. to 8:30 p.m. Saturday scanning is currently available from 9:00 a.m. to 5:00 p.m. approximately twice per month. An MRI technologist certified by the Lane Neuroimaging Lab is required to be present for all scans unless prior authorization is obtained in writing

Additional Documentation Required

To complete your application, please submit additional required documentation to be reviewed by the MRI User’s Committee. Please note that the maximum file size for uploading is 3MB. You may also submit these required materials to the Lane Neuroimaging Lab Manager, Ginny Hayes: vhayes@wisc.edu

For studies involving HUMAN subjects:

1. Human Subjects Research Protocol 2. IRB approval letter 3. Approved Consent Form(s) 4. Copy of grant that is providing funding for scans

Drop files here or

For studies involving ANIMAL subjects:

For studies involving Animal Subjects, please include the following for your application to be reviewed by the MRI User’s Committee: 1. Approved Animal research protocol 2. Research Animal Resources Center Committee Approval Letter 3. Copy of grant that is providing funding for scans

Drop files here or

Requirements for MRI Access:

Upload the following documentation for EACH LAB MEMBER who requires MRI Access: 1. Documentation of Human Subjects Research Training 2. HIPAA authorization form(s)

Drop files here or

MRI Fee Policy:*

The MRI Scanning fee is $500 per hour for all persons affiliated with the University of Wisconsin System and its Associates. There is a minimum one-hour charge for all scans. Additional time in the same scanning session will be billed in half hour increments. A Radiology fee of $50 is charged for all over reads. At your request, you will be scheduled for a specific time slot on the MRI calendar. Lab policy is that any time slot cancelled, within one week of the scheduled scan time or less, will be charged the entire session scan fee, unless another investigator requests to use that particular scan time.

I have read and agree to the above fee policy.

Your Name (digital signature)*

HERI MRI Research Application

Specific Study Information

MRI Scan Session Information:

Additional Documentation Required