MRI Research Application Form

HERI MRI Research Application

Lane Neuroimaging Lab MRI Research Application Form
  • Specific Study Information

  • (limited to 8 characters or less)
  • MRI Scan Session Information:

  • 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:
  • 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, 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
  • 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
  • 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.