Order for Research Study in Emory Radiology

This form is used for ordering and scheduling imaging mandated by a research protocol for Outpatients ONLY. It includes information relevant to any biopsies that are to being carried out and potential Department of Pathology involvement.

This form must be completed and faxed to 404-778-3335 for non-invasive imaging studies prior to calling the Radiology scheduling office @ 404-778-9729 and for invasive procedures faxed to 404-712-7122 prior to calling the Radiology scheduling office @ 404-712-0566. Incomplete forms will not be accepted.

P.I. Name ______

Name of Research Coordinator ______

Coordinator Contact (PIC or phone number) ______

Grant Name or Acronym ______

Bill to [check one of the following] [ ] Grant Smart Key # ______[ ] Insurance ICD-10 Code Z00.6 ICD-10 Code(s): ______

Diagnosis: ______

RESEARCHER: This order is to be used only for those patients who are participating in an IRB approved study with an Emory PI. This request is only valid for the below procedures:

Patient/Subject Name: (print): ______Patient/Subject DOB ______/______/______

______PRINT: Name of ordering physician

______/______/______Ordering physician signature Date signed (Required) Time signed (Required)

Radiology exam(s) ordered (please include short bulleted list of specific protocols/procedures):

Biopsies ordered (please include short bulleted list of specific protocols/procedures for both radiology & pathology):

Coordinator must answer the following questions. 1. Does this imaging exam have to be performed at a particular location or on a particular piece of equipment? a. [ ] No b. [ ] Yes b.i. Name of location: ______b.ii. Specific equipment name: ______2. The imaging protocol for this study is: a. [ ] Standard imaging protocol (same as used for a clinical study) b. [ ] Use the special protocol for this grant (must be approved by Dept of Radiology Vice Chair for Research) 3. The radiology images are to be interpreted as follows: a. [ ] Normal interpretation process b. [ ] Interpreted only by Dr. ______(this must be prearranged) c. [ ] There is to be no interpretation (this is indicated in the IRB approved informed consent) 4. The biopsy specimens are to be processed &/or interpreted as follows (please check all that apply): a. [ ] Normal processing &/or interpretation process via internal, Emory pathology – if there is an Emory-specific internal collaborator please specify:______. b. [ ] Specimens are to be sent out for external processing (please describe how specimens are to be processed and to whom they will be given at the time of the procedure______. c. Please specify to the extent possible the amount of tissue needed for the biopsy (e.g., four 18 ga cores) d. [ ] There is to be no interpretation (this is indicated in the IRB approved informed consent) 5. The report is part of the Medical Record: a.i. [ ] Yes a.ii. [ ] No (this is indicated in the IRB approved informed consent) 6. The images are to be archived in PACS (same process as for clinical images): a.i. [ ] Yes a.ii. [ ] No 7. If images are to be put on a CD please check box here: [ ] YES 2016.07