Applications

For the applications that are Word files, please click on the appropriate link, fill in, save file with your name and date (i.e., "Jones_08_15_2005.doc") and send as an attachment to melissa.myers@uphs.upenn.edu.

Animal CT Research
Research Application Form: Image Anonymization Account Request
Request for Image De-identification
Human CT Research
Specimen/Phantom CT Research
Approved IV Contrast Agent for CT Research Studies Request Form
Pregnancy Test Documentation Form
Human IV Contrast for CT Research Studies
CT Patient Screening Questionnaire
Radiology Outpatient Form


If there are any questions regarding the applications, please contact Melissa Myers at 215-349-5891 or melissa.myers@uphs.upenn.edu.

CACTIS meetings are held the third Wednesday of the month at 1 PM. All submissions must be received no later than 12:00 PM the Friday before.

Submission Requirements

CACTIS IS NOW ACCEPTING ONLY ELECTRONIC SUBMISSIONS.

Human Subjects Submission

Approval for human subjects can be obtained by submitting the following for initial review:

• CACTIS application form
• consent form
• CT protocol
• Protocol summary
• Full protocol
• Copy of Radiography/Fluoroscopy operators certification (for studies not using a technologist)
• Drug brochure / package insert for outside contrast agents.

The following will need to be on file prior to study start and full approval:

• A copy of the IRB approval letter
• IRB approved consent form
• Copy of the radiation safety approval letter
• Confirmation of BEN account number from your departments BA in writing
• Confirmation of participation from the radiologist listed on your application

Applications may be submitted to Melissa Myers, CACTIS coordinator at the below address.
Please submit at least six weeks prior to study start date.

• Melissa M. Myers, BS, RT(R), RDMS
  Radiology Department, CVI Section
  3400 Spruce Street
  Silverstein 1, c/o Harold Litt, MD, PhD
  Philadelphia, PA 19104

Studies that are time sensitive or require specific scanning days will need the approval of Felicia Jefferson, chief CT technologist. Her contact information is provided on the CACTIS members page.


The charges for human studies are as follows:

• Non-industry:
  • $250.00 per ½ hour
    $400.00 per hour

• Industry-sponsored:
  • $350.00 per ½ hour
    $550.00 per hour

• Contrast Agents:
  • $25.00 per IV contrast injection
    $10.00 oral contrast (per use)

• Image Reconstruction:
  • $100 per study
  Neuroradiologist reader fee:
  • $50.00 per CT exam
  Exam De-identification fee for non-CACTIS CT’s
  • $25.00 per CT exam

Please Note: PROTOCOLS USING THE CACTIS PRICING DO NOT NEED A FAMILY ACCOUNT ESTABLISHED FOR THE CT PORTION. CACTIS STUDIES ARE NOT BILLED THROUGH THE HOSPITAL SYSTEMS.

Animal Studies Submission

Approval for animal studies can be obtained by submitting the following for initial review:

• CACTIS application form
• CT Protocol
• Protocol summary
• Full protocol
• List of potential risks and steps to avoid them
• Copy of radiography/fluoroscopy operators certification (for studies not using a technologist)
  

The following will need to be on file prior to study start and full approval:

• A copy of the IACUC approval letter
• A copy of the animal transfer letter
• A copy of the radiation safety approval letter

Applications may be submitted to Melissa Myers, CACTIS coordinator at the below address.
Please submit at least six weeks prior to study start date.

• Melissa M. Myers, BS, RT(R), RDMS
  Radiology Department, CVI Section
  3400 Spruce Street
  Silverstein 1, c/o Harold Litt, MD, PhD
  Philadelphia, PA 19104

Only complete submissions will be accepted for review. Animal studies require special time slots which occur after clinical hours and sometimes on weekends. Please be aware that due to this type of scheduling, ample time is needed for study start up. For more information please contact Felicia Jefferson.

The charges for animal studies are as follows:

• Non-industry:
  • $250.00 per ½ hour
    $400.00 per hour

• Industry-sponsored:
  • $350.00 per ½ hour
    $550.00 per hour

• Contrast Agents:
  • $25.00 per IV contrast injection
    $10.00 oral contrast (per use)

• Image Reconstruction:
  • $100 per study

Specimen/Phantom Studies Submission

Approval for all non-human or non-animal studies can be obtained by submitting the following:

• CACTIS application form
• Full protocol
• Protocol summary
• CT Protocol
• Specimen studies: documentation for obtaining specimens
• Copy of radiography/fluoroscopy operators certification (for studies not using a technologist)

The following will need to be on file prior to study start and full approval:

• A copy of the IRB approval letter

Applications may be submitted to Melissa Myers, CACTIS coordinator at the below address.
Please submit at least six weeks prior to study start date.

• Melissa M. Myers, BS, RT(R), RDMS
  Radiology Department, CVI Section
  3400 Spruce Street
  Silverstein 1, c/o Harold Litt, MD, PhD
  Philadelphia, PA 19104

Studies that are time sensitive or require specific scanning days will need the approval of Felicia Jefferson, chief CT technologist. Her contact information is provided in the CACTIS procedures manuals.

If bringing in specimens from outside labs, a letter from Infection Control is required. Specimens coming from UPHS's Pathology labs are considered "in-house" and can be scanned as such.

The charges for specimen/phantom studies are as follows:

• Non-industry:
  • $250.00 per ½ hour
    $400.00 per hour

• Industry-sponsored:
  • $350.00 per ½ hour
    $550.00 per hour

• Contrast Agents:
  • $25.00 per IV contrast injection
    $10.00 oral contrast (per use)

• Image Reconstruction:
  • $100 per study

Renewal Process

All studies submitted through CACTIS must be renewed on a yearly basis unless changes to the study protocol involve CT. Please submit all amendments that involve only the CT portion of the study to the committee when received by the principal investigator. These will need to be approved by the committee before the changed research can be put into effect in the clinical setting.

All studies submitted through CACTIS must be renewed on a yearly basis.
To obtain an approval for renewal:

Human Studies:

• CACTIS application form
• A copy of the IRB re-approval letter
• IRB approved consent form (if no changes, please submit just the stamped page)
• A copy of the IRB continuing review form
• CT Protocol
• Protocol summary (only if changes occurred from previous year)
• Protocol amendments (if applicable)
• Progress report as submitted to the IRB

Animal Studies:

• CACTIS application form
• A copy of the IACUC re-approval letter
• A copy of the new animal transfer letter
• CT Protocol
• Protocol summary (only if changes occurred from previous year)
• Protocol amendments (if applicable)
• Progress report as submitted to the IRB

Specimen/Phantom Studies:

• CACTIS application form
• A copy of the IRB re-approval letter
• Protocol amendments (if applicable)
• Protocol summary
• CT Protocol
• Specimen studies: documentation for obtaining specimens
  

Renewal applications may be submitted to Melissa Myers, CACTIS coordinator at the below address.
Please submit at least six weeks prior to study end date.

• Melissa M. Myers, BS, RT(R), RDMS
  Radiology Department, CVI Section
  3400 Spruce Street
  Silverstein 1, c/o Harold Litt, MD, PhD
  Philadelphia, PA 19104