Pre-Clinical Imaging Research Project Application Form

CIBM Pre-clinical research project application

Applicant information

Applicant first name *

Applicant last name *

Applicant’s E-mail *

Applicant’s phone number *

Applicant is not PI

Principal Investigator first name

Principal Investigator last name

PI’s E-mail

PI’s phone number

Institution *

Laboratory/Unit *

Resource information

Please select resources requested *

MRI 9.4T @EPFL

MRI 14.1T @EPFL

PET @EPFL

PET @HUG

Number of MRI hours (MRI 9.4T@EPFL)

Number of MRI hours (MRI 14.1T@EPFL)

Number of PET hours (PET@EPFL)

Number of PET hours (PET@HUG)

Project Information

Project Title *

Project Tag name (max 20 char) *

Project expected start date *

Project expected end date *

Funding source *

Funding start date *

Funding end date *

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

Authorization number for animal experiments *

Number of animals or ex vivo samples requested *

Project type *

Application in-vivo

Application phantoms/solutions, ex-vivo

Development in-vivo

Development phantoms/solutions, ex-vivo

PhD

PostDoc

Demonstration/Teaching

To be defined

Ethics information

Ethics committee approval *

Approved

Submitted

Not applicable

Name of ethics committee

Ethics committee document

Drop a file here or click to upload Choose File

Maximum upload size: 20MB

Project description

Keywords that describe your project (separate with ,) *

Background and significance *

0 of 250 max words

Research plan *

0 of 250 max words

Imaging protocol *

0 of 250 max words

Approach to image data analysis

0 of 250 max words

Other comments

0 of 250 max words

Other project requirements

Special requirements and additional services (9.4T MRI@EPFL)

Assistance with data acquisition

Assistance with data analysis

MR expert needed

Vet needed for surgery before MRI scans

Vet needed for animal physiology monitoring

Operator service

Specific service

Safety briefing

Operator training

Other requirementsOther requirements

Special requirements and additional services (14.1T MRI@EPFL)

Training for operating scanner independently

Assistance with data acquisition

Assistance with data analysis

MR expert needed

Vet needed for animal monitoring

Vet needed for surgery before MRI scans

Other requirementsOther requirements

Special requirements and services (PET@EPFL)

Training for operating scanner independently

Assistance with data acquisition

Assistance with data analysis

MR expert needed

Vet needed for animal monitoring

Vet needed for surgery before MRI scans

Other requirementsOther requirements

Special requirements and services (PET@HUG)

Training for operating scanner independently

Assistance with data acquisition

Assistance with data analysis

MR expert needed

Vet needed for animal monitoring

Vet needed for surgery before MRI scans

Other requirementsOther requirements

Billing

Account number (if known)

Billing address of the PI *

Billing address of the PI

Billing address of the PI

Billing address of the PI

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

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Country

Agreement *

I have read the facility/infrastructure access policy and guidelines and I understand the fee structure associated to this project application.

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