HIRF Research Proposal
Please complete the following questionnaire, attaching all relevant documents, and submit to HIRFAdministration@health.qld.gov.au. HIRF will assign modality lead(s) based on the type(s) of imaging you require. If you would like to meet with the modality lead(s) at HIRF to discuss technical issues prior to submission of this form please organise a meeting through HIRFAdministration@health.qld.gov.au.
General Information
Project Name (Long Title)
Short title of Project
*
Affiliation
MNHHS
UQ
QUT
QIMR-B
Other
Principal Investigator (PI)
*
PI Contact Phone Number
Please enter a valid phone number.
Format: (00) 0000-0000.
PI Email Address
*
example@example.com
PI ORCID
Co Investigator (if applicable)
Total Number of CIs on project
Please list total number of CIs on project
Research Co-ordinator (RC)
RC Address
RC Contact Phone Number
Please enter a valid phone number.
Format: (00) 0000-0000.
RC Email Address
example@example.com
Project Overview
Project Description
Background & Aims
Methods
Trial Sponsor (if applicable)
Funding Details
Proposed Number of Participants
Proposed Study Duration Start
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Proposed Study Duration Finish
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Modality of Imaging
MR
Functional MR
MR Contrast required?
PET/MR
PET/CT
CT Contrast required?
*** For PET services please specify tracer***
Number of scans per participant
Duration of each scan session anticipated
Acquisition details (protocol, sequences, radiopharmaceutical/tracer, novel sequences etc.)
Specify Ancillary equipment (including in-scannerequipment etc.)
Describe cohort (particularly what medical support or patient handling may be required)
HREC Number and Date (if available)
SSA Number and Date(if available)
Imaging Data Transfer Requirements
Cloud upload
SFTP site upload
USB (you will need to provide)
Other
Do you need analysis support?
Yes
No
If yes, what type of analysis support?
Invoicing Details
Contact Details for Invoicing
First Name
Last Name
Invoicing Email Address
example@example.com
Invoicing Phone Number
Please enter a valid phone number.
Format: (00) 0000-0000.
Signature of PI
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Preview PDF
Submit
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