Martinos Center for Biomedical Imaging

IMAGER PROJECT ACCOUNT APPLICATION FORM (new accounts)

Account Type:
Project Title:
Principal Investigator:
Department:
Institution:
Address:
Full Email Address:
Phone #: (nnn) nnn-nnnn
Fax #: (nnn) nnn-nnnn
Account Users (The user accounts that will use the scanners or schedule slots on the scanners):
Person responsible for running the project on site (name, email, phone):	Name: Email: Phone:
Source(s) of support (funding agency, grant title, grant #, PI):

For Pilot Accounts only:
If data is to be used for a grant application, provide potential funding source and application deadline.	Source: Deadline:

For Funded Accounts only:
Funding Source(s):	Grant Number(s): Grant Title(s):
Fund Number:
Active Dates:
Imaging dollars per year:
Administrating Institution:
Contact Person:	Name: Email: Phone:
Billing Address: ( if outside MGH )

Is this project an explicit collaboration with the Center's P41 Regional Regional Resource Grant, the Center for Functional Neuroimaging Technologies?	Project 1: High Resolution Anatomical Modeling
	Project 2: Ultra High Field MR Technology for Functional Imaging
	Project 3: Spatiotemporal Brain Imaging
	Project 4: Functional Diffuse Optical Tomography of the Brain

Subjects:	Description / Number
Normals:	/
Patients:	/
Animals:	/

IRB/SRAC Approval Number:

IMAGING SYSTEM:	HOURS NEEDED PER SUBJECT:
1.5T (whole body, Avanto):
3.0T (whole body, TRIO):
7T:
3.0T (16 cm bore):
4.7T (33 cm bore):
9.4T (21 cm bore):
14T (8.9 cm bore Spectrometer):
MEG/EEG
MicroPET
IVIS

Proposed Start Date:
Special Patient Care, Imaging or Equipment Needs:	Note: Studies that require physiological monitoring are invited to utilize the GCRC supported resources (e.g.INVIVO or AD Instruments (in any bay) or the AVOTECH Headphones in Bay4, nursing staff, etc.). Projects using these resources must submit their protocol to the GCRC and provide Karen Dervin with a copy of the GCRC approval letter. Alternatively, investigators may wish to supply their own monitoring equipment, which must be approved in writing by Mary Foley.
Very Brief Study Description:
Include: Study Aims Background/Significance Subjects Imaging Protocol Behavioral Tests Response / physiological monitoring Data Processing / Analysis Strategy
Comments:

All studies that utilize the imaging resources of the Martinos Center benefit from the technology developed by our NCRR- funded Regional Resource, the Center for Functional Neuroimaging Technologies. We therefore ask that you acknowledge this grant (P41RR14075) in any publications and presentations resulting from the project you are now proposing. Please check here to confirm

NOTE: In order to complete your application for a funded account, you must email a pdf of the following to Karen Dervin (karend@nmr.mgh.harvard.edu):

For a modular grant: a copy of the Human or Animal Subject Page including the Targeted Enrollment Form
For a non-modular grant: a copy of the Budget and Justification page

Your account application is not complete until these forms are received.

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