JDMI RESEARCH
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Project Request Form
External Impact Review Form

JDMI Research

JDMI RESEARCH
People
Services
Project Request Form
External Impact Review Form

EXTERNAL IMPACT REQUEST FORM

External Impact Review Form

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Introduction

This form is to request formal approval by JDMI research of proposed projects. Please submit this form only if you have already discussed your project with JDMI research. If you have not discussed your project already, please submit a Project Request Form for preliminary review.

Name*
First Last
Email*
Phone*
Company/Institution*
Project Lead / Principal Investigator (if applicable)*
Department/Division
Site/Organization*

Project Description
250 word limit for each sub-section
Full Project Name*
Abstract*
Rationale/Background*
What are the study hypotheses or research questions?*
Primary Objectives - How will they be measured?*
Secondary Objectives - How will they be measured?*
Target Start Date*
MM slash DD slash YYYY
Target Completion Date*
MM slash DD slash YYYY
Site where this study will take place*
- Sinai Health Systems
- Women's College Hospital

Services Requested
Type of Imaging - Values Section 1.1
Type of Imaging (1.1)
Select as many types as needed and enter in details below
- Image-guided Biopsy
- CT
- PET/CT
- MRI
- PET/MRI
- XRAY
- Ultrasound
- Nuclear Medicine
- Tumour Measurements
- Interventional
Imaging-guided Biopsy
Type of Imaging - Detail (1.2)
- Soft Tissue / Lung
- Bone / Spine
- Breast
- Other
Other
Is a clinical report required?*
- Yes
- No
Number of patients*
Time point(s) explained*
Word limit 100 characters
Time point(s) numerical*
CT
Type of Imaging - Detail (1.2)
- Head/Neck and CAP (HNCAP)
- Whole Body
- C, T or L-Spine, and Extremities
- Abdomen/Pelvis (AP)
- Brain
- Chest
- Head/Neck (HN)
- Chest/Abdomen (CA)
- Chest, Abdomen, Pelvis (CAP)
- Cardiac
- Other
Other
Type of Imaging - Imaging Parameters (1.3)
- With Contrast
- Without Contrast
Is a clinical report required?*
- Yes
- No
Number of patients*
Time point(s) explained*
Word limit 100 characters
Time point(s) numerical*
PET/CT
Type of Imaging - Detail (1.2)
- WB + Extremities
- Cardiac
- Brain
- Head and Neck
- Whole Body (WB)
- Other
Other
Type of Imaging - Imaging Parameters (1.3)
- FDG Tracer
- Other Tracer
Other
Is a clinical report required?*
- Yes
- No
Number of patients*
Time point(s) explained*
Word limit 100 characters
Time point(s) numerical*
MRI
Type of Imaging - Detail (1.2)
- Pelvis
- MRE
- Head/Neck and Abdomen, Pelvis (HNAP)
- Head/Neck and CAP (HNCAP)
- Head/Neck (HN)
- Whole body (WB)
- Chest
- Cardiac
- Breast
- Brain
- C, T or L-Spine, and Extremities
- Abdomen/Pelvis (AP)
- Chest, Abdomen, Pelvis (CAP)
- Other
Other
Type of Imaging - Imaging Parameters (1.3)
- With Contrast (GAD)
- Without Contrast (GAD)
Is a clinical report required?*
- Yes
- No
Number of patients*
Time point(s) explained*
Word limit 100 characters
Time point(s) numerical*
PET/MRI
Type of Imaging - Detail (1.2)
- Pelvis
- Head/Neck and Abdomen, Pelvis (HNAP)
- Head/Neck and CAP (HNCAP)
- Head/Neck (HN)
- Whole body (WB)
- Chest
- Cardiac
- Breast
- Brain
- C, T or L-Spine, and Extremities
- Abdomen/Pelvis (AP)
- Chest, Abdomen, Pelvis (CAP)
- Other
Other
Type of Imaging - Imaging Parameters (1.3)
- With Contrast (GAD)
- Without Contrast (GAD)
- FDG Tracer
- Other Tracer
Other
Is a clinical report required?*
- Yes
- No
Number of patients*
Time point(s) explained*
Word limit 100 characters
Time point(s) numerical*
XRAY
Type of Imaging - Detail (1.2)
- Extremities (Per body part)
- Abdomen (1-2 views)
- Thoracic Spine (1-2 views)
- Chest (1-2 views)
- Cervical Spine (1-2 views)
- Lumbar Spine (1-2 views)
- Portable (in addition to body part)
- Mammography (Unilateral)
- Mammography (Bilateral)
- 3 Spine (1-2 views)
- Fluroscopy / Video-fluroscopy
- Skeletal survey (up to 14v)
- Mammography (Unilateral)
- Other
Other
Is a clinical report required?*
- Yes
- No
Number of patients*
Time point(s) explained*
Word limit 100 characters
Time point(s) numerical*
Ultrasound
Type of Imaging - Detail (1.2)
- Portable (in addition to body part)
- Portal Vein/Transplant Doppler
- Breast (per breast)
- Pelvic - limited
- Abdominal - Limited
- Peripheral artery or Vein (per extremity)
- Pelvic - complete
- Intracavity Transvaginal / Transrectal)
- Abdominal - Complete
- Carotid/vertebral artery (bilateral)
- Other
Other
Is a clinical report required?*
- Yes
- No
Number of patients*
Time point(s) explained*
Word limit 100 characters
Time point(s) numerical*
Nuclear Medicine
Type of Imaging - Detail (1.2)
- BMD/DEXA - Total Body
- BMD/DEXA - Hip & Spine
- GFR by blood sample
- Total Body Bone Scan
- MUGA – Rest with volume
- V/Q Lung Scan
- Other
Other
Is a clinical report required?*
- Yes
- No
Number of patients*
Time point(s) explained*
Word limit 100 characters
Time point(s) numerical*
Tumour Measurements
Type of Imaging - Detail (1.2)
Is a clinical report required?*
- Yes
- No
Number of patients*
Time point(s) explained*
Word limit 100 characters
Time point(s) numerical*
Interventional
Type of Imaging - Detail (1.2)
- Line Insertion (e.g for apheresis)
- Intratumoral Injection
- Other
Other
Is a clinical report required?*
- Yes
- No
Number of patients*
Time point(s) explained*
Word limit 100 characters
Time point(s) numerical*

Transfer of Images
Is a transfer of images required for your study?*
- Yes
- No
How will images be transfered?
Select all that apply
- Burn images to CD/DVD
- Electronic transfer of images (AG Mednet)
- Archived image retrieval (blocks of 4 hours)
- Data-transmittal form to be completed by JDMI staff
Please state why your project does not require image transfer?

JDMI Radiologist
Do you have JDMI Radiologist co-investigator?*
- Yes
- No
JDMI Radiologist Name
First Last
Specify delegated task of co-investigator

Radiologist
Is a dedicated radiologist reviewer required?*
- Yes
- No
Radiologist Reviewer Information
First Last
Do you have imaging acquisition guidelines?*
Describe any additional medical imaging services required?

REB
Is this a research project involving humans?*
- Yes
- No
Has REB Approval been obtained?
- Yes
- No
REB Number*
Does this project involve healthy volunteers?*
- Yes
- No
Does this project involve patients?*
- Yes
- No
Does this project involve animals?*
- Yes
- No

Multi-Site Project
Is this a multi-site project?*
- Yes
- No
Number of sites
Who is the lead/coordinating site?
Specify sites involved

Funding
Estimated Budget*
Type of Funding Source*
- Grant
- Industry
Name of company, granting agency, or funding source*
What is the status of funding from this source?*
- Obtained
- Pending
- Not yet submitted

Study Design*
- Prospective
- Retrospective
Describe the study design & methodology*
Provide a standalone synopsis of the study. Include: type of study (pilot, phase I, II, III, IV)
Name
This field is for validation purposes and should be left unchanged.

Contact

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Toronto, ON
M5G 1X6
Email: jdmiresearch@uhn.ca

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JDMI RESEARCH
People
Services
Project Request Form
External Impact Review Form

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