Human MRI project application form

CIBM project application human MRI

Project Information

Project type *

Application

Development

PhD

PostDoc

Demonstration/ teaching

Project Title *

Project Tag (max 20 char) *

Expected project start date *

Expected project end date *

Applicant first name *

Applicant last name *

Applicant’s E-mail *

Applicant’s phone number *

Principal Investigator first name *

Principal Investigator last name *

PI’s E-mail *

PI’s phone number

Institution *

Laboratory/Unit *

Number of extra persons needing booking access (calpendo) * 0 1 2 3 4 5 Number of extra persons needing booking access (calpendo)

Extra person 1

Extra person 1’s email

Extra person 2

Extra person 2’s email

Extra person 3

Extra person 3’s email

Extra person 4

Extra person 4’s email

Extra person 5

Extra person 5’s email

Type of population *

Patients

Healthy subjects

OtherOther

Population age range *

Resource information

Resource requested *

7T@EPFL

3T@CHUV

3T@HUG

3T@BBL

7T@Campus Biotech

Number of MRI hours (7T@EPFL)

Number of MRI hours (3T@BBL)

Number of MRI hours (3T@CHUV)

Number of MRI hours (3T@HUG)

Number of MRI hours (7T@CB)

Funding and ethical information

Funding source *

Funding start date *

Funding end date *

Ethics committee Approval *

Approved

Submitted/ In progress

N/A

Name of ethics committee

Ethics Committee document

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Maximum upload size: 20MB

Project requirements

Other special requirements and services (7T@EPFL)

Training for operating scanner independetly

Assistance with data acquisition

Assistance with data analysis

MR expert needed

Visual stimulation

Auditory stimulation

Eye-tracker

Physiological measurements

Other requirementsOther requirements

Other special requirements and services (3T@CHUV)

Training for operating scanner independetly

Assistance with data acquisition

Assistance with data analysis

MR expert needed

Visual stimulation

Auditory stimulation

Tesla high end reconstruction server

Eye-tracker

Response buttons or trackball

Physiological measurements

Other requirementsOther requirements

Other special requirements and services (3T@HUG)

Training for operating scanner independetly

Assistance with data acquisition

Assistance with data analysis

MR expert needed

Visual stimulation

Auditory stimulation

Olfactory stimulation

Tactile/ Thermal/ Electrical stimulation

Eye-tracker

Physiological measurements biopac

Other requirementsOther requirements

Other special requirements and services (3T@BBL)

Training for operating scanner independetly

Assistance with data acquisition

Assistance with data analysis

MR expert needed

Visual stimulation

Auditory stimulation

Olfactory stimulation

Tactile/ Thermal/ Electrical stimulation

Eye-tracker

Physiological measurements biopac

Other requirementsOther requirements

Other special requirements and services (7T@CB)

Training for operating scanner independetly

Assistance with data acquisition

Assistance with data analysis

MR expert needed

Visual stimulation

Auditory stimulation

Olfactory stimulation

Eye-tracker

Physiological measurements biopac

Other requirementsOther requirements

Project description

Keywords that describe your project (separate with ,) *

Background and significance *

Research plan *

Imaging protocol *

Approach to image data analysis *

Other comments

Billing

Billing address *

Billing address

Billing address

Billing address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

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