IMAGER PROJECT ACCOUNT APPLICATION FORM (new accounts)

Account Type:
Project Title:
Principal Investigator:
Department:
Institution:
Address:
Full Email Address:
Phone #:
(nnn) nnn-nnnn
Fax #:
(nnn) nnn-nnnn
Account Users
(The user accounts that will use the scanners or schedule slots on the scanners or non-imaging resources):
Permission Group
(The UNIX permission group that data uploaded to the archive should be put in. Only users accounts in this group will have read access.):
Person responsible for running the project on site (name, email, phone):
Source(s) of support (funding agency, grant title, grant #, PI):

For Development Accounts only:
Please explain what type of Development you will be doing (NMR, MEG, TMS, multimodal hardware or software etc.) and how it will be of general use to the full Martinos Center community.

For Pilot Accounts only:
If data is to be used for a grant application, provide potential funding source and application deadline.

For Funded Accounts only:
Funding Source(s):
Fund Number:
Active Dates:
Imaging dollars per year:
Administrating Institution:
Contact Person:
Billing Address:
( if outside MGH )

   
Subjects: Description / Number
Normals: /
Patients: /
Animals: /

 

 

IRB/SRAC Approval Number:

 

 

IMAGING SYSTEM: HOURS NEEDED PER SUBJECT:
1.5T (Bay 2):
3T (Bays 1, 3, and 4):
3T Connectome (Bay 8):
3T MR/PET (Bays 6 and 7):
7T (Bay 5):
14T (8.9 cm bore Spectrometer):
15T (13cm horizontal bore):
4.7T (33 cm bore):
9.4T (21 cm bore):
MEG/EEG:
MiniPET:
IVIS
TMS*

*Prior approval of the Martinos TMS committee is required.

 

 

Proposed Start Date:
Special Patient Care, Imaging or Equipment Needs:

Note: Imaging studies that require physiological monitoring are invited to utilize the CRC supported resources (e.g.INVIVO or AD Instruments (in any bay) or the AVOTECH Headphones in Bay4, nursing staff, etc.). Projects using these resources must submit their protocol to the CRC and provide Karen Dervin with a copy of the CRC approval letter. Alternatively, investigators may wish to supply their own monitoring equipment for use during scanning, which must be approved in writing by Mary Foley.

Very Brief Study Description:
Include:
  • Study Aims
  • Background/Significance
  • Subjects
  • Imaging Protocol
  • Behavioral Tests
  • Response / physiological monitoring
  • Data Processing / Analysis Strategy
Comments:
Is this project an explicit collaboration with the Center's P41 Regional Resource Grant, the Center for Functional Neuroimaging Technologies? Project 1: High Resolution Anatomical Modeling
Project 2: Ultra High Field MR Technology for Functional Imaging
Project 3: Spatiotemporal Brain Imaging
Project 4: Functional Diffuse Optical Tomography of the Brain

 

 

All studies that utilize the imaging resources of the Martinos Center benefit from the technology developed by our NCRR- funded Regional Resource, the Center for Functional Neuroimaging Technologies. We therefore ask that you acknowledge this grant (P41RR14075) in any publications and presentations resulting from the project you are now proposing.

Please check here to confirm


NOTE: In order to complete your application for a funded account, you must email a pdf of the following to Karen Dervin (karend@nmr.mgh.harvard.edu):

  1. For a modular grant: a copy of the Human or Animal Subject Page including the Targeted Enrollment Form
  2. For a non-modular grant: a copy of the Budget and Justification page

Your account application is not complete until these forms are received.

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