IMAGER PROJECT ACCOUNT APPLICATION FORM

There are two kinds of project accounts available: funded and unfunded.

Funded Accounts: Projects that are supported by grant funding or by industry are billed hourly and may request a regular scanning time on the research scanner schedules. A fund number and billing information must be provided. All applications for a funded account must also provide a Human or Animal Subject Page including the Targeted Enrollment Form from their modular grant or a Budget and Justification page from their non-modular grant. These pages in pdf form must be emailed to Karen Dervin or your account cannot be set up.

Unfunded Accounts: Unfunded accounts are available to Martinos Center faculty engaged in research for the development of NMR, MEG or TMS, or multimodal hardware, software, and imaging techniques that will be of general use to the Martinos Center community. Additionally, in certain cases, unfunded accounts may be created for projects that are directly related to new, innovative and promising lines of research, such as protocol and technical development, that benefit the Martinos Center imaging core or user community.

Account Type *

• Funded
• Unfunded

Project Title *

Principal Investigator *

PI Email Address *

Institution *

Department *

PI Phone Number (xxx-xxx-xxxx)

Requester email (filling out this form if other than PI)

Account Users

(The user accounts that will use the scanners or schedule slots on the scanners or non-imaging resources)

Permission Group

(The UNIX permission group that data uploaded to the archive should be put in. Only users accounts in this group will have read access.)

If not PI, the person responsible for running the project on site (name, email, phone)

For Unfunded Accounts only: Please explain what type of work you will be doing (NMR, MEG, TMS, multimodal hardware or software etc.) and how it will be of general use to the full Martinos Center community. *

For Funded Accounts only: Funding Sources *

• NIH
• Other (specify)

Other *

Sponsor Number(s) / Sponsor Title(s)

Peoplesoft Number (cost center). If there is no cost center, give us information on invoicing Institution *

Active Dates *

Imaging dollars for each year of project *

Billing Contact Person (name / email / phone) if outside MGH

Billing Address (if outside MGH)

IRB / IACUC Approval Number (enter "phantom" for phantoms) *

Subjects (Normals): Description

Subjects (Normals): Number

Subjects (Patients): Description

Subjects (Patients): Number

Subjects (Animals): Description

Subjects (Animals): Number

Hours Needed Per Subject: 3T (Bays 1, 3, and 4)

Hours Needed Per Subject: 3T Connectome 2.0 (Bay 8)

Hours Needed Per Subject: 3T MR/PET (Bays 6 and 7)

Hours Needed Per Subject: 7T (Bays 2)

Hours Needed Per Subject: 14T (8.9 cm bore Spectrometer)

Hours Needed Per Subject: 15T (13cm horizontal bore)

Hours Needed Per Subject: 4.7T (33 cm bore)

Hours Needed Per Subject: 9.4T (21 cm bore)

Hours Needed Per Subject: MEG/EEG

Hours Needed Per Subject: Mediso PET/CT

Hours Needed Per Subject: IVIS

Hours Needed Per Subject: TMS *

*Prior approval of the Martinos TMS committee is required.

Proposed Start Date

(mm/dd/yyyy)

Special Patient Care, Imaging or Equipment Needs

Note: Investigators may wish to supply their own monitoring equipment, task related equipment, or any custom built equipment for use during scanning. These devices must be approved in writing by Grae Arabasz after a analysis has been performed by our Core Imaging Team. These devices will then be tagged and labeled accordingly prior to being allowed in the Zone IV environment. Please reach out to Grae Arabasz for more details on this process.

Brief Study Description *

Include: Study Aims, Background/Significance, Subjects, Imaging Protocol, Behavioral Tests, Response / Physiological Monitoring, Data Processing / Analysis Strategy

Is this project an explicit collaboration with the Center's P41 Regional Resource Grant, the Center for Mesoscale Mapping?

• Project 1: Cross-scale integration and modeling
• Project 2: Acquisition technology for in vivo functional and structural MR imaging at the mesoscopic scale
• Project 3: Removing the biological limits for in vivo human brain MRI
• Project 4: Integrating Electromagnetic Multifocal Brain Stimulation and Recording Technologie

NOTE: In order to complete your application for a funded account, you must email a pdf of the following to Karen Dervin (karend@nmr.mgh.harvard.edu):

1. For a modular grant: a copy of the Human or Animal Subject Page including the Targeted Enrollment Form
2. For a non-modular grant: a copy of the Budget and Justification page

Your account application is not complete until these forms are received.

All studies that utilize the imaging resources of the Martinos Center benefit from the technology developed by our NCRR- funded Regional Resource, the Center for Mesoscale Mapping. We therefore ask that you acknowledge this grant (P41-EB030006) in any publications and presentations resulting from the project you are now proposing.

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