IMAGER PROJECT ACCOUNT APPLICATION FORM (new accounts)

Account Type

Funded

Pilot

Development

Project Title

Principal Investigator

Department

Institution

Address

Full Email Address

Phone Number (xxx-xxx-xxxx)

Fax Number (xxx-xxx-xxxx)

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)

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 Sources

NIH

Other (specify)

Other

Peoplesoft Number (cost center)

Active Dates

Imaging dollars per year

Administrating Institution

Contact Person (name / email / phone)

Billing Address (if outside MGH)

Subjects (Normals): Description

Subjects (Normals): Number

Subjects (Patients): Description

Subjects (Patients): Number

Subjects (Animals): Description

Subjects (Animals): Number

IRB / IACUC Approval Number

Hours Needed Per Subject: 3T (Bays 1, 3, and 4)

Hours Needed Per Subject: 3T Connectome (Bay 8)

Hours Needed Per Subject: 3T MR/PET (Bays 6 and 7)

Hours Needed Per Subject: 7T (Bays 2 and 5)

Hours Needed Per Subject: 14T (8.9 cm bore Spectrometer)

Hours Needed Per Subject: 15T (13cm horizontal bore)

Hours Needed Per Subject: 4.7T (33 cm bore)

Hours Needed Per Subject: 9.4T (21 cm bore)

Hours Needed Per Subject: MEG/EEG

Hours Needed Per Subject: Mediso PET/CT

Hours Needed Per Subject: IVIS

Hours Needed Per Subject: TMS*

*Prior approval of the Martinos TMS committee is required.

Proposed Start Date (mm/dd/yyyy)

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 Grae Arabasz.

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 Mesoscale Mapping?

Project 1: Cross-scale integration and modeling

Project 2: Acquisition technology for in vivo functional and structural MR imaging at the mesoscopic scale

Project 3: Removing the biological limits for in vivo human brain MRI

Project 4: Integrating Electromagnetic Multifocal Brain Stimulation and Recording Technologies

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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):

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

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

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 Mesoscale Mapping. We therefore ask that you acknowledge this grant (P41-EB030006) in any publications and presentations resulting from the project you are now proposing.

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IMAGER PROJECT ACCOUNT APPLICATION FORM (new accounts)