Project Request Form – Micro CT equipment

Micro-Imaging Research Facility – Usage Agreement
Center for Dental Research, Loma Linda University School of Dentistry

Instruction: One form for each project

Section 1: User Information

Principal Investigator:

First Name

Last Name

PI email:

PI Phone:

PI Position:

Department / School:

Funding Source:

Internal

External

Section 2: Micro Imaging and Image Analysis

Density of sample examination:

Section 3: Project Information

Project Title:

If applicable:

irb- iacuc

Which Chemical are you using?

Which radiation and dose?

Project Status:

options

Project Description

Project Description: Please provide an abstract/summary including a) hypothesis, b) groups including the number of samples to be imaged, c) parameters for the Micro CT, d) anticipated problems, and e) other information relevant to imaging and analysis. The information is used for Micro CT scanning and analysis, and will be kept confidential

Upload File

One file only.
2.05 KB limit.
Allowed types: jpg, jpeg, png, txt, pdf, doc, docx.

Researchers authorized

Researchers authorized to plan and schedule experiments (Last Name, First name). If you have extramural collaboration, specify colleague institution, e-mail, and phone number.

How many Collaborators are in your group?

Section 4: Budget Estimation

Start Date:

End Date:

Estimates:

Imaging Time:

Analysis Time:

Training:

Total Budget: $

Cost Center

Credit

BY SUBMITTING THIS FORM:

I acknowledge that I am voluntarily providing my personal information to Loma Linda University Health. I understand that in order to keep my health information private, I will abstain from using this form to provide details about my medical condition or that of the individual I am requesting information for. I will limit the amount of information shared on this form to only my contact information in order to receive the requested information. I understand that I may contact Loma Linda University Health directly at 855-558-1100 in case I need to discuss confidential or private information. I further understand that I may be contacted by a representative from LLUH in response to my inquiry via telephone or mail. I understand LLUH will not respond via email when communicating confidential or private information

Signature

Authorization Signatures:

PI:

Date PI Signed:

Cost Center Administration:

Date Cost Center Admin Signed:

Department Chair:

Date Dept. Chair Signed:

Micro-Imaging Research Facility (MRF) – Office Use Only

User LLU ID:

Project ID:

Project Approval:

Date:

Estimated Cost:

Rate Information:

LLUSD

LLU - Other Schools

Non-LLU

Credit

Authorization Signatures:

MRF Staff:

MRF Date Signed:

MRF Director:

MRF Director Date Signed:

COVID-19

Section 2: Micro Imaging and Image Analysis

Section 3: Project Information

Section 4: Budget Estimation

Authorization Signatures:

Micro-Imaging Research Facility (MRF) – Office Use Only

Authorization Signatures: