The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Imaging Session Registration Form

Research Staff: Please answer the questions below. When you are done, please save the form. You will advance to the next survey (MRI Screening Form).

If this is a human study and you are completing the forms in person with the participant, you may continue to fill out the form. After the study, the Technologist will fill out the Completion Report.
If this is a human study and you are emailing a link to the participant, please 1) Select Save & Return Later; 2) Email the link to the participant; and 3) Email the Return Code to the participant. After the study, the Technologist will fill out the Completion Report.
If this is a phantom study, you may exit the MRI Screening Questionnaire. When the session is done, please access the Study Completion Report using the Record/Status Dashboard, fill in the information, and save the form.

Thank you!

PI's Name (or names for Co-PI studies):

* must provide value

PI's Home Institution:

* must provide value

University of Illinois at Urbana-Champaign

Carle Foundation Hospital

University of Illinois at Urbana-Champaign and Carle Foundation Hospital Co-PI's

Other

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Name of Institution:

Last Name of CIAIC Collaborator

Home Institution of CIAIC Collaborator

University of Illinois at Urbana-Champaign

Carle Foundation Hospital

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Study Contact's Name, if other than PI:

Study Contact's Email Address

Study Contact's Phone Number:

CIAIC Protocol Number:

* must provide value

Purpose of imaging session:

Institution for billing or time allocation:

* must provide value

University of Illinois at Urbana-Champaign

Carle Foundation Hospital

Jointly billed UIUC-Carle study

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Billing Status:

CFOP (leave blank for developmental studies)

Carle billing center number (leave blank for developmental studies)

Type of imaging session:

* must provide value

IRB of Record:

Please indicate the IRB of Record:

One-word description of body part to be imaged (e.g., brain, leg, etc.):

Does the imaging protocol require the use of a contrast agent?

Yes

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Does the imaging protocol use first level mode?

Yes

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Equipment:

Carle 3T

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.