PRIME Protocol Proposal Form
All investigators requesting to conduct research in the PRIME Centre are required to submit a Protocol Proposal Form to obtain centre approval. The Protocol Review Committee meets regularly to review submitted Protocol Proposal Forms. Approved proposals will receive a Certificate of Approval.
After completing the form, please click the Submit button at the end of the form.
Study Title
* must provide value
Today M-D-Y
Study Title: Study Nickname (if applicable): Date: Principal Investigator (PI) Information
Name: Institution:
Faculty:
Department:
Position/Rank:
Other Academic or Health Centre Affiliations (if applicable) :
Phone: Email:
PI Name
* must provide value
PI Other Academic/Health Centre Affiliations (if applicable):
PI Phone
* must provide value
PI Email
* must provide value
Primary Contact Information (Correspondent) (if different from PI)
List the members of your team you would like to be granted access to the PRIME Centre. These individuals will be responsible for your study at the PRIME Centre and for participants entering the facility. Including the PI, how many members of your team will require access to PRIME?
How many team members need access
* must provide value
None 1 2 3 4 5
Team Member 1 Name:
Phone:
Email:
Position:
Role in study: Credentials for Operating Equipment:
Required Training:
TM 1 Credentials for operating equipment
Team Member 2 Name:
Phone:
Email:
Position:
Role in study: Credentials for Operating Equipment:
Required Training:
TM 2 Credentials for operating equipment
Team Member 3 Name:
Phone:
Email:
Position:
Role in study: Credentials for Operating Equipment:
Required Training:
TM 3 Credentials for operating equipment
Team Member 4 Name:
Phone:
Email:
Position:
Role in study: Credentials for Operating Equipment:
Required Training:
TM 4 Credentials for operating equipment
Team Member 5 Name:
Phone:
Email:
Position:
Role in study: Credentials for Operating Equipment:
Required Training:
TM 5 Credentials for operating equipment
Has your study been approved by the UBC Research Ethics Board?
Yes No
Approved Research Studies
Please attach the following documents when submitting this form: a) UBC RISe application b) study protocol as per section 9.1.A of RISe application, and c) REB approval certificate
UBC REB #
Approval Date
Expiry Date
Please upload the following documents UBC RISe application
Study Protocol
REB Approval Certificate
Today M-D-Y
Today M-D-Y
Non- Approved Research Studies
Please explain the reason as to why this study has not been approved by the REB. If approval is in progress, please note the date of expected approval.
REB not approved reasoning
When is your requested start date?
When is your expected end date?
Today M-D-Y
Today M-D-Y
Does this study involve human participants in PRIME? (If yes, please complete the boxes below, if no skip to non-participant studies)
Yes No
Number of Participants:
Requested time per visit:
Does this study involve multiple visits per participant?
Multiple visits per participant
Yes No
Number of visits per participant: Total number of visits:
Time interval between visits:
Number of visits per participant
Time interval between visits
What is the subject of your research? (I.e., placental, animal studies, etc.) Requested time for use of research equipment or space: (I.e., 4 hours a day for 6 weeks.)
Are you requesting pilot hours? If yes, how many? If yes, what is the purpose of the pilot hours?
Are you requesting pilot hours?
Yes No
If yes, what is the purpose of the pilot hours?
Funding Information
source of payment to PRIME :
Funded (if yes, specify source): Funding to be confirmed No funding
Source of payment to PRIME:
UBC Workday Cost Center Cheque Other (specify):
Ultrasound technologist support is not provided but can be arranged on an individual basis by the PI.
Ultrasound Technologist Requested?
Are you requesting the use of PRIME equipment? If no, skip to Space Requests.
If yes, please indicate below what equipment you are requesting.
Ultrasound Technologist Requested?
Yes No
Are you requesting the use of PRIME equipment? If no, skip to Space Requests.
Yes No
Ultrasound Imaging Systems
(If applicable, select probe(s))
TA
TA 4D
EV
(If applicable, select probe(s))
TA
EV
Pediatric
(If applicable, select probe(s))
TA
TA 4D
EV
If applicable, select probe(s): TA
Ultrasound Simulators There is additional orientation and training required for the use of the ultrasound simulators.
CAE Vimedix Ultrasound Simulator
Intelligent Ultrasound ScanTrainer
Data Backup & Export All DICOM data will be exported to the PRIME Research PACS. Once the session is complete, all data/images will be permanently deleted from the hard drive of the ultrasound machine.
AVI-SPL Audiovisual Equipment
Gazepoint HD Remote 150Hz Eye Tracker
System
INVOS NIRSensors (neonatal sensors)
Location of Equipment Use Please note, only the following equipment can be used outside the facility and require additional approval from the Protocol Review Committee: Ultrasonix Sonixtouch Q+ with GPS, Sonix DAQ, Philips Lumify Remote Scanning System, NIRS OxiplexTS, NIRS INVOS 5100C System, INVOS NIRSensors, and the Gazepoint HD Remote 150Hz Eye Tracker System.
Where will the equipment be used?
other location (specify):
Are you requesting the use of PRIME space?
If yes, please indicate below what space you are requesting.
Yes No
Imaging Suites Imaging suites are included with the use of Ultrasound Imaging Systems, if you have requested the use of an Ultrasound Imaging System, please DO NOT indicate request of a suite unless additional space is required.
(Suite #1 is Adjacent to the main U/S department and PRIME waiting room. This room i ncludes a private bathroom inside the suite. Suite #4 is inside the waiting room door)
(Inside waiting room door)
Imaging Suite #2-3 (includes philips Epiq Elite)
RA Drop Down Space in Main U/S Dept.
Additional Study Information
Please provide a lay abstract of the proposed research including brief background, specific aims of the project and the research plan. This abstract should provide enough detail to allow evaluation of safety, feasibility, and design. If necessary, please attach additional materials to support this proposal. Please ensure the following questions are answered within your abstract. 1. What is the goal of your study? 2. If your study involves human participants, how will you be recruiting them? 3. Will your study visits be scheduled or ad-hoc? Please note, we will review ad-hoc studies on a case-bycase basis to determine feasibility based on facility capacity at the time of your request. 4. What equipment/facility space is needed (PRIME facility or user supplied)? And how will the equipment/facility be used? 5. Would you like your study to be promoted on the PRIME website? If yes, please submit a written sample of the content you would like to be published along with this application. Please note, we cannot publish recruitment materials. For reference of material that can be published, please visit https://primeresearchcentre.med.ubc.ca/research/research-projects/ .
Attach Additional Materials:
Submit
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