Clinical Research Imaging Core (CIC) Service Center

Study Title

Penn IRB Protocol Number

UPCC number

Target enrollment

PI Name (First, Last)

Is the PI an Abramson Cancer Center Member?

PI School

Other school

PI Department

Clinical Research Professional Contact (First, Last Name)

Email:

Department holding grant

Name of the Grant/Award

Funding Type

Project ID ('nickname') listed on the funding page of the PBR system, if applicable (please ask your BA and/or lab manager)

REQUIRED: 26-digit BEN Funding Account # to be used for payment of approved CIC Services (please ask your BA and/or lab manager)

Business Administrator (first, last name)

BA Email

Type of Service Requested

Expected duration of utilizing this service center for this project (example: until 12/31/2026).

Is there a Radiologist listed on study that is being paid a percent effort for the biopsy procedures?

If yes, please list the Radiologist.

Please list the page number in the protocol that describes the biopsy procedure

Is the image guided biopsy procedure considered standard of care (procedure would be performed even if patient was not on study)?

If yes, are you taking additional tissue samples for the purposes of research?

Type of image guidance required for biopsy

Type of biopsy tissue sampling

Which anatomical regions may require biopsy?

How many biopsy procedures are requested for this protocol? Please list total number for enrolled patients combined (example: target enrollment goal=5, 2 mandatory biopsy= 10 total biopsy procedures).

Total number of mandatory biopsies:

Total number of optional biopsies:

Frequency of biopsy procedures (example: one time or every 6 weeks)

Provide a detailed description of the time points for the biopsy (or biopsies)

How should we handle the specimen?

Please describe how we should store the sample (i.e.
Formaldehyde)

Will a member of the study team be present at each procedure?

Please describe the billing mechanism for this study (Example: biopsy procedures will be billed to the Research Billing Account or insurance):

Please check the service(s) requested for TRAC
Note: A one-time protocol initiation fee will be charged at the time of activation within the billing system.

Phase:

Tumor type:

Treatment type:

Treatment cycle:

Number of baseline exams (expected) per patient

Number of follow-up time points per patient

Imaging cycle:

Is disease required at baseline?

Does this protocol require evaluable disease (target or non-target lesions) at baseline?

Does this protocol require measurable disease (target lesions) at baseline?

Radiologic reading criteria

Modality

If other, describe

If other, please describe

AV Line Placement: total number of lines needed:

Estimated number of scans to be anonymized.

RADCORE: Clinical Research Professional Services. Please describe what type of staffing support you need.

Protocol

Informed Consent Form

Imaging and/or Lab manual

Supporting Document(s)

PI approval

-By signing this document I understand that I am allowing my funding source and or sponsored program to be charged via service center. I understand that a service center charges the current rate (financial policy#2115) on file and I hereby abide by the university policies and procedures governing allowable charges to my sponsored program or departmental funding. I understand that failure to have an active funding account at the time of service will result in my Department suspense account being charged for the work performed.

Name of person completing form (first, last)

Signature of person completing this form
Signature and verification of application and billing
-my signature below indicates the above information was completed based on my understanding of the protocol.