Indiana Center of Excellence
in BioMedical Imaging
Pilot Study Application


This printable form may be downloaded using the link shown here {printable Pilot Study Application} and saving it to your hard drive for your personal use. Type in the spaces next to or below each heading, adding more lines as needed. You may attach supplemental materials to this form to help explain your project. Please submit all applications electronically to info@in-cebi.net with the subject IN-CEBI Pilot Application.

Principal Investigator:

Name

Department

Phone

FAX

Email

Campus Mailing Address

From which IN-CEBI Program are you Requesting Funds?

  • INGEN Initiative – Approved projects will receive an 80% reduction on the technical imaging fees.




Which Scientific Area of Interest Best Fits Your Application?

If you have selected Genomics, please specify your Genomics Scientific Area of Interest:

Title of Proposal

Project Duration

Start Date

End Date
(ONE-year maximum duration)

Request for Exemption from
ONE year Maximum Study Duration


Requested Extension End Date

Include justification for request for
exemption from one-year maximum
study duration.


Regulatory Information

If human or animal subjects will be used in this study, provide IRB or LARC study number and approval date. If pending, provide submission date:
*Regulatory approval is not required for submission, however scheduling for any imaging modality cannot be initiated without evidence of the required regulatory approval(s).

IRB Study Number

IRB Study
Approval Date

IRB Study
Submission Date
     

IACUC Study Number

IACUC Study
Approval Date

IACUC Study
Submission Date


If radiation will be used in this study that is outside "standard of care", identify radiation safety permit number:


Research Plan

Background and Significance
(Provide a concise statement of the rationale for performing this research project. One page maximum)


Budget
(Provide a budget for your proposed project. Proof of supplemental funding {e.g. extramural funds, letter of support, etc} must be provided for those items in the project not covered by this award.)


Hypotheses/Specific Aims
(Provide a concise statement of the scientific hypotheses or research goals and specific objectives. One-page maximum)


Methods
(Describe the techniques proposed for data acquisition and analysis. Please include sufficient detail to allow evaluation of scientific merit. Five pages maximum)


Target Funding Sources
(The primary objective of the pilot imaging program is the collection of sufficient preliminary data to compete for extramural funding. Please identify your target funding sources and anticipated date for your grant submission)




Imaging Modalities Requested

Type of Equipment

Needed?

# of Subjects

Scan time per subject
1.5T Whole Body MRI (GE Signa LX)
3T Whole Body MRI
PET (Siemens HR+)
PET-CT (Siemens Biograph 16)
CT (Siemens Biograph 16)
IndyPET II
microCT (EVS)
Autoradiography
9.4T NMR Vertical Bore (Varian)
9.4T MRI Horizontal Bore (Varian)
Interventional Radiology

Please list any Radiopharmaceuticals that are needed for your study
(PET & Autoradiography Studies Only!)


Other equipment/supplies that are needed for your study
(Please provide details)