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Radiology Research Feasibility Assessment

To ensure that Radiology resources will be available for human research at Jefferson, protocols that requires imaging assistance must be submitted for review by the Department of Radiology. A formal request for review is initiated by completing the RadRequest webform that may be found on the Jefferson Office of Human Research Protection site. A complete log of all correspondences will be maintained by the Department of Radiology. 

ATTENTION – Study Team Must Read Before Proceeding
  1. All fields below should be thoroughly read, comprehended, and answered to the best of your knowledge. Failure to do so may result in extended reviewing time.
  2. Informal or verbal requests for Radiology resources will not be acceptable.
  3. Any updates to the imaging guidelines after this submission or Radiology approval will need to be resubmitted for evaluation.
  4. The PIs should review the imaging protocol and be mindful of patients’ implant status and imaging tolerance. 
  5. Please e-mail the latest protocol and/or imaging manual version to RadRequest@jefferson.edu. Requests submitted without supporting document(s) will not be evaluated - no exceptions.

Form Completed by:

Section I: General Information

Is the PI the author of the protocol/study? *
Has this study has already been submitted to the IRB?

Section II: Study Details

For this study, patients are:
What phase is the trial in?

Section III: Imaging Details

Is the TJUH standard clinical imaging protocol acceptable for this study? *

If you answer “Yes”, this means there is no questionnaire, no training, and no phantom imaging required. If the protocol requires ANY of the above, please check “No”. 
 

Is there any phantom imaging or a volunteer imaging required? *

*If yes, you may be required to supply a volunteer for imaging. 

Is there specific online training required for imaging team? *
Is there a questionnaire to be completed? *
Is contrast required for study? *Please note, double dose contrast is not permitted
Identify all Radiology modalities for which imaging is required for the study:
Identify all body parts for which imaging is required for the study (brain, abdomen, pelvis, spine, etc.)
Can you attest that you, as the Study Coordinator, have fully read the Imaging Trial requirements for this study? *

Section IV: Staff Resources

Identify if additional Radiologist support for this study is required:
Has a radiologist with knowledge of the protocol been identified as a co-investigator?
If not applicable, type N/A
If not applicable, type N/A
If applicable; if not applicable, type N/A
If not applicable, type N/A
If not applicable, type N/A
If not applicable, type N/A

Section V: Additional Comments