MRI Research Application Form HERI MRI Research Application Lane Neuroimaging Lab MRI Research Application Form Specific Study InformationProject 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Cell Phone* Email* Project Funding Source* Project Grant Number (from Funding Source)* Project Funding Period (starting date)* Month Day Year Project Funding Period (ending date)* Month Day Year 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 writingAdditional Documentation RequiredTo 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.eduFor 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 Select files Max. file size: 100 MB. 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 Select files Max. file size: 100 MB. 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 Select files Max. file size: 100 MB. 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)*