Date Today D-M-Y
MUSC Faculty Full Name* must provide value
Faculty's First and Last Name
Faculty MUSC Email* must provide value
Enter Faculty's MUSC Email Address ( PI@musc.edu)
MUSC Faculty MUSC Net ID* must provide value
MUSC Net ID
MUSC Faculty Contact Phone* must provide value
Enter Faculty's Contact Number (843) 792-XXXX
Project Name* must provide value
Calpendo Project Name
Abbreviated Project Name* must provide value
CBI Server Folder Name (no spaces). Reccomended less than 20 characters
Project Code* must provide value
IRB Pro #/ IACUC # / Enter Samples if running non in-vivo that does not require IACUC approval
Grant #* must provide value
Grant Title* must provide value
Brief Description of the Project* must provide value
Award Start Date* must provide value
Today M-D-Y
Award End Date* must provide value
Today M-D-Y
Grant PI's Full Name* must provide value
Would the PI like an email each time this study's data has been pushed from scanner? Yes
No
Other Investigators 1 First and Last Name
Other Investigators 1 Role Role
Other Investigators 2 First and Last Name
Other Investigators 2 Role Role
Other Investigators 3 First and Last Name
Other Investigators 3 Role Role
Other Investigators 4 First and Last Name
Other Investigators 4 Role Role
Other Investigators 5 First and Last Name
Other Investigators 5 Role Role
Other Investigators 6 First and Last Name
Other Investigators 6 Role Role
Other Investigators 7 First and Last Name
Other Investigators 7 Role Role
Other Investigators 8 First and Last Name
Other Investigators 8 Role Role
Other Investigators 9 First and Last Name
Other Investigators 9 Role Role
Other Investigators 10 First and Last Name
Other Investigators 10 Role Role
Other Investigators 11 First and Last Name
Other Investigators 11 Role Role
Other Investigators 12 First and Last Name
Other Investigators 12 Role Role
Other Investigators 13 First and Last Name
Other Investigators 13 Role Role
Other Investigators 14 First and Last Name
Other Investigators 14 Role Role
Number of Unique Subjects* must provide value
Total Number of Unique Scan Subjects
Number of Unique Follow-up Scans* must provide value
Number of Follow-up Scans for each Unique Subject
Total Number of Scans* must provide value
Total Number of Scans for Project
Subject Population* must provide value
i.e. Children (age range), Healthy, Parkinson, Stroke
Scanner Used* must provide value
3T Human
7T Animal
Estimated Scan Time (minutes)* must provide value
Scan Time = Protocol time + 10 min for instructions/positioning, +5 for Biopac, +10 per MRS voxel location, +10 for eyetracker
Will you use the mock scanner for this study?* must provide value
Yes
No
Will you reserve a screening room for this study?* must provide value
Yes
No
Do you have a specific screening room you will use?* must provide value
Screening Room 2/Mock Scanner
Screening Room 3
Screening Room 4
Screening Room 5
Don't Know/Any will do
Will a Phantom be used for this study?* must provide value
Yes
No
Will this study use spectroscopy?* must provide value
Yes
No
Is this a longitudinal study?* must provide value
Yes
No
Type of Study* must provide value
Commercially Funded (Billed at $1300/hr)
Federally/Foundation Funded ($650/hr)
Early Stage Investigator Rate ($325/hr)
Developmental Study
7T Funded Study ($200/hr)
Type of Study* must provide value
Funded (Billed at $200/hr)
Developmental Study
Funding Source* must provide value
Funding Administrator's Name* must provide value
Funding Administrator's Email* must provide value
Funding Administrator's Phone* must provide value
Department* must provide value
(Please fill out what you know. If you do not know this information, select Don't Know and we will discuss at project set up) Scanner Protocol* must provide value
Functional
Resting State
T1
T2
DKI
DTI
MRS
Other
Don't Know
Click All that Apply
What other scanner sequences will you use for this study?
Handpad Used* must provide value
None
FORP Handpad (most common)
FORP 2 Button
FORP Dynamometers
Brainlogics PST (no longer supprted)
MRA Button Box
Other
Don't Know
What other handpad will you use for this study?
Handpad Specifics* must provide value
Right
Left
Both
NA
Don't Know
Coils Used* must provide value
32 Channel
20 Channel
TMS Coil
Body Wrap
Spine Matrix
Knee
Neck
Tx/Rx
Other
Don't Know
Click All that Apply
What other coils will you use for this study?
Ancillary Equipment* must provide value
Avotec Ear Plugs
Avotec Headset
Biopac ECG
Biopac RSP
Biopac EDA
Biopac PPG
Eyetracker
Brainproducs EEG
Eckert Sensimetrics Audio
Siemens Physio
Other
Don't Know
What other equipment will you use for this study?
Additional Comments/Setup Notes
Please be aware that anyone working with subjects at the MRI must complete the MRI Safety Course. Registration for this course is at the CBI website: User Name 1 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 2 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 3 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 4 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 5 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 6 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 7 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 8 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 9 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 10 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 11 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 12 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 13 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 14 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
User Name 15 Enter Full Name
Phone Number
MUSC Email
MUSC Net ID
Access Data on CBI Server? Yes
No
Send email when data has been pushed from scanner? Yes
No
Submit
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