MRN Price Quote Request Form
Please complete this form to request a price quote for use of the imaging scanners (MRI, MEG, EEG) and other MRN services. You will be contacted by MRN's Sponsored Research office with a price quote within two business days. Please reference the price quote number and period of performance (as noted on the quote) when submitting purchase orders to MRN.
Sign in to Google to save your progress. Learn more
Principal Investigator name *
Name of person completing form *
Email address of person completing form *
IRB number, if known
If multiple studies, please list all numbers
Name of your institution *
e.g. UNM, UNMHSC, VA, LANL, etc.
Mechanism through which the scans and/or services being quoted will be paid. *
Choose all that apply.
Funding Source/Name *
NIH, NSF, DOD, University funds, foundation, commercial, legal, etc. If private funding, please list the name of the company.
If funded by a federal contract or grant, please provide Prime Award #.
Project Start Date *
MM
/
DD
/
YYYY
Project End Date *
MM
/
DD
/
YYYY
Are you requesting a quote for MRI scans? *
Required
If yes, 3T scanner or 1.5 (mobile) scanner?
Clear selection
If 1.5T mobile scanner, please provide scan location.
City, State
Number of MRI scan sessions
Length of each MRI scan session
in hours
Type of MRI scan
Brain, lung, abdomen, breast, etc.
Contrast?
# of vials
Power injector (includes IV supplies)?
# of injectors
Oxygen?
# of uses
IV supplies only?
# of IV supplies
Are you requesting a quote for MEG scans?
If yes, number of MEG scans
Length of each MEG scan session
in hours
Do you need a technician for participant setup?
Are you requesting a quote for EEG scans?
If yes, will it be done simultaneously with any of the following?
Choose all that apply
Clear selection
Number of EEG scans
Do you need a technician for participant setup?
Are you requesting a quote for any additional supplies?
Please describe, e.g. pregnancy tests, drug tests, etc. NOTE: All supplies quoted at cost + F&A
Are you requesting a quote for image analysis services or training services?
If yes, describe type of service or analysis (e.g. fMRI), estimated # of hours and name of individual completing the training or analysis, if known.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of MRN. Report Abuse