Application for RESEARCH
Protocol Using Animals
Bio-Molecular Imaging Center (BMIC)
Univ er s it y of W a sh in gt on
Sout h L a k e Unio n Ca mpu s
81 5 M erc e r St ., Se at t l e, W A 9 8 10 9
Project #YY-NNNN
Date Received:
( N o t e : i n e a c h " F o r m F i e l d " c e l l , c l i c k i n s i d e s h a d e d a r e a t o h i g h l i g h t & t h e n b e g i n e n t e r i n g yo u r d a t a )
( T o e n t e r a n " X" i n t o a n y " c h e c k b o x" , d o u b l e - c l i c k o n t h e c h e c k b o x & s e l e c t " c h e c k e d " f r o m " D e f a u l t
va l u e " )
PROTOCOL
1.
INFORM ATION
PROJECT TITLE
SHORT TITLE (30 characters max.) which should be generic for the online schedule that is viewable by the general public
ANTICIPATED STARTING DATE
PROJECTED END DATE
CONTACT
2.
INFORMATION
Principal Investigator
Name:
Title:
Department:
Box:
Address:
Phone:
Fax:
E-mail:
3.
Primary Contact
Name:
Title:
Department:
Box:
Address:
Phone:
Fax:
E-mail:
FUNDING
4.
AGENCY
INFORM ATION
Funded Research Project Budget Information
If funded project has a UW budget, please complete the information below:
UW Budget Number:
Budget Name:
Source of Funding:
Duration of Funding: Start date
End Date:
If funded project is not affiliated with the University of Washington, please provide the following information:
Purchase order number:
Contact Name:
Phone Number:
Contact Address:
Protocol Development hours requested?
D:\81895105.doc
Yes
No
1
Bio-Molecular Imaging Center (BMIC)
Univ er s it y of W a sh in gt on
Sout h L a k e Unio n Ca mpu s
81 5 M erc e r St ., Se at t l e, W A 9 8 10 9
5.
Application for RESEARCH
Protocol Using Animals
Project #YY-NNNN
Date Received:
Brief summary of the proposed project.
a) Objectives:
b) Research Plan:
D:\81895105.doc
2
Application for RESEARCH
Protocol Using Animals
Bio-Molecular Imaging Center (BMIC)
Univ er s it y o f W a sh in gt on
Sout h L a k e Unio n Ca mpu s
81 5 M erc e r St ., Se at t l e, W A 9 8 10 9
Project #YY-NNNN
Date Received:
Attachm ent E – CBIC MRI Pro cedures
MRI PROCEDURES
(To enter an "X" into each "check box" below, double-click on the check box & select "checked" from the "Default value")
6.
Indicate who will be responsible for animal handling during imaging
BMIC core personnel
Personnel listed on this protocol in conjunction with BMIC core staff
Personnel listed on this protocol working without assistance from BMIC staff (list personnel):
7.
List the following for animals to be imaged: a) Number; b) Species; c) Sex; d) Age
a) Number:
;
b) Species:
;
c) Sex:
;
d) Age:
8.
Duration and number of scanning sessions requested: a) Duration for each imaging session; b) Interval
between sessions; c) Total number of imaging sessions per animal; d) Total number of sessions
a) Duration
of each imaging session:
;
requested.
b) Interval between sessions:
;
c) Total number of sessions per animal:
;
d) Total number of sessions requested:
9.
Indicate whether the animals to be imaged have been exposed to any of the following:
NO
YES
Infectious and hazardous agents (If yes, describe agents & usage precautions below)
Human cells or blood (If yes, describe usage precautions below)
Viral vectors (If yes, describe vectors & usage precautions below)
Radioisotopes
If "yes" to any of question number #4 above, please describe the agents or viral vectors that will be used and the precautions that will be
taken to prevent personnel exposure:
√
10.
Use of Contrast Agents
No contrast agents will be used
Contrast agents will be used in this study. If yes, please answer the following:
Provide the following information for each contrast agent: a) Volume per injection & total volume per imaging session; b) Route & frequency of
administration; c) Time interval between subsequent intervals
a) Volume/injection & total volume/imaging session:
b) Route & frequency of administraiton:
c) Time interval between subsequent intervals:
11.
;
;
Describe any procedures or treatments that will be given or performed on the animal(s) prior to or during
imaging (e.g. Tail vein injections, perfusion, oral administration, etc.)
√
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Application for RESEARCH
Protocol Using Animals
Bio-Molecular Imaging Center (BMIC)
Univ er s it y o f W a sh in gt on
Sout h L a k e Unio n Ca mpu s
81 5 M erc e r St ., Se at t l e, W A 9 8 10 9
12 .
NO
Project #YY-NNNN
Date Received:
Indicate the additional instrumental equipment will be used:
YES
Physiological monitoring system
ECG gating
Respiratory gating
Anesthesia
13.
Describe the agents used for anesthesia (name of the agent, administration, dosage)
√
14.
IACUC policy on rodent handling in bio-imaging core
I have read and agree to adhere to the IACUC Policy on Rodent Handling in BMIC
I have read and agree to adhere to the IACUC Policy on Rodent Handling in BMIC with the following exceptions. (list exceptions and provide
scientific justification for requested change)
15.
Animals originating from non-UW facilities
Please indicate the name of the non-UW institute from which the animals originate:
√
A copy of the IACUC approved animal protocol from the non-UW institution is attached.
A copy of a complete protocol animal application for approval by the UW IACUC is attached.
16.
BMIC Administrative Use
A. Date application received:
Study Number:
B. Cost for the use of the BMIC 3T scanner:
$
/hour x
hours/each session=a): $
Total sessions=b):
Total cost for the entire imaging study: a) x b)
Charges for requested supplies
Optical Disks - $95/ea
DAT Tape - $6.00/ea
Retrieval of Exam - $51.00
$
$
$
$
TOTAL SUPPLIES
$
C. Reviewed and approved by the BMIC director
Chun Yuan, PhD
Signature
Date
Please submit this application as well as any requested documentation in both hard copy (signed) and
electronic copy (MS Word document without signature) to Bio-Molecular Imaging Center, Box
358050, [email protected].
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