Project Name: _______________________________________________________________

Project Name: ________________________________________________________________

Type: expl feas pilot grant trial Proposed Time Period: __________ to___________

Principal Investigator^*: __________________________________

phone___________ pager_____ email_______

IRB# _______ IRB PI___________________

Radiology Department Collaborator(s): ______________________________________

phone___________ pager_____ email_______

Present Funding: _________________________________________________________________________

Anticipated Funding: ______________________________________________________________________

Co-investigators: _________________________________________________________________________

___________________________________________________________________________________________

Affiliations: ^*______________________________________________________________________________

___________________________________________________________________________________________

Introduction(Note: attach References): ___________________________________________________________ _____________________________________________________________________________________________

_____________________________________________________________________________________________

Scientific Objective: _______________________________________________________________________

_____________________________________________________________________________________________

Expected Benefits to Society: _______________________________________________________________

_____________________________________________________________________________________________

Expected Benefits to Radiology Department:

Immediate: _______________________________________________________________________________

Anticipated: ______________________________________________________________________________

_____________________________________________________________________________________________

Materials and Methods:

Radiology Equipment Requested:

MR/CT/SPECT scanner committment: unit:____________ time__________ o/r/c_____

Special Software:___________________________________________________________________________

MR/CT/SPECT scanner committment: unit:____________ time__________ o/r/c_____

Special Software:___________________________________________________________________________

DATA strorage: media___________ volume_________duration________

PACS storage: volume_________duration___________

Laboratory Equipment:_______________________________________________________________________

______________________________________________________________________________________

Computers/Software:________________________________________________________________________

______________________________________________________________________________________

Special Hardware/Software:____________________________________________________________________

______________________________________________________________________________________

Radiology Personnel Requested:

radiologist: person____________ time__________ o/r/c_____

physicist/mathematician/computer: person______________ time_______________ o/r/c_____________

data processing support: person______________ time_______________ o/r/c_____________

clinical technician: person____________ time__________ o/r/c_____

Radiology Space Requested:_________________________________________________________________

Specific Tasks(Target Date/Responsible Person):

1)___________________________________________________________________________________

2)___________________________________________________________________________________

3)___________________________________________________________________________________

4)___________________________________________________________________________________

5)___________________________________________________________________________________

6)___________________________________________________________________________________

7)___________________________________________________________________________________

8)___________________________________________________________________________________

Expected Results: __________________________________________________________

_________________________________________________________________________

References:

1) R.S.Menon, S. Ogawa, X. Hu, J.P.Strupp, P.Anderson and K.Ugurbil, BOLD Based Functional MRI at 4 Tesla Includes a Capillary Bed Contribution: Echo-Planar Imaging Correlates with Previous Optical Imaging Using Intrinsic Signals. Magn. Reson. Med. 33: 453-459 (1995).

2) D.Malonek and A.Grinvald, Interactions Between Electrical Activity and Cortical Microcirculation Revealed by Imaging Spectroscopy: Implications for Functional Brain Mapping. Science 272: 551-547 (1996).

3) M. Bari, What makes brain neurons run? Science 276: 196-198 (1997).