Center for Radiology Research Resources (CR3)

Center for Radiology Research Resources (CR3) - Request for Services

Please complete this form to initiate review of research studies that require imaging.

Next Steps:

We will set up an onboarding meeting with your study team to discuss your needs, clarify questions, and obtain necessary information for imaging managers and radiologists to review.

If your study requires research reads, sponsor required forms, or upload to central site, turnaround time may be lengthened as we confirm feasibility with the imaging team and imaging sites.

Today's Date*

Full Study Title*

Short Study Title (if any)

Department

Examples: Neurology, Urology, Pediatrics, Hematology/Oncology

PI Name*

Do not need to include: Dr., MD, etc

PI email*

PI Phone

Study Coordinator Name*

For multiple names, separate with a comma

Study Coordinator Email*

Study Coordinator Phone*

Project Manager (if applicable)

Project Manager Email

Accounting Contact Name*

Name and/or email

IRB Status*

Select

IRB #

OnCore# or CPRC# (if not yet assigned, please enter TBD)*

Funding Source*

Select or enter value

Funding Source Details

Please include the name of the B&I sponsor, the foundation, or other funding source

Target Start Date

Projected Enrollment #

Radiology services requested (select all that apply)*

Select

Other Services Requested

Imaging Modality (select all that apply)*

Select

IMAGE TRANSFER: Site Number/Trial name on portal

Other Modality

Imaging Location*

Select

Imaging Location Comments

Other Comments

Please attach protocol, imaging manual documents, and/or sponsor required imaging forms

Additional forms should be related to Radiology/Imaging only

Drag and drop files here or

PLEASE NOTE:

SELECT THE CHECKBOX BELOW TO SEND YOURSELF A COPY OF YOUR SUBMISSION.

You will also receive information related to CR3 fees for your records.

Send me a copy of my responses

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