TJUH Imaging Research Request Form

In order to ensure that radiology imaging equipment/resources will be available for human research at TJU, research protocols that require radiology assistance with imaging should be submitted for review by the Department of Radiology. A formal request for review must be submitted by the initiating investigator prior to submission for IRB approval, or any time information is required about availability and/or cost of imaging for a specific study/proposal. The request for review is initiated by completing a webform that may be found on the website of the Jefferson Office of Research Administration. Informal/verbal requests for equipment availability and study prices will no longer be acceptable. A complete log of all imaging research requests and responses will be maintained by the Department of Radiology to facilitate imaging research on campus.

Note: Radiology will provide a clinical report on every study (as per department policy) to the requesting physician or PI. Any standard imaging procedure, non-standard imaging, post-processing, measurements, case report form, data transfer request, or non-routine radiological interpretation required for the study must be specified on this form, or they will not be provided when patients are imaged for the study.

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    Principle Investigator information

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    Study Coordinator

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    Technical Contact

    (If applicable) This person may be a representative study sponsor and should have technical knowledge about the exam and the exam protocol parameters).
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    Study Details

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    Please enter a number.
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    Must be a number greater than 0
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    Final instructions

    Note: When a patient presents for imaging, he/she should have a script that states “Imaging Research Study”, the study name, IRB control #, PI name and the type of imaging requested (which should match the protocol).