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Core Biopsy*  FORMCHECKBOX  Fine Needle Aspiration* *CT, Ultrasound or Fluoro Guidance as per interventionalist Site:  FORMCHECKBOX  Lymph Node  FORMCHECKBOX  Liver  FORMCHECKBOX  Lung  FORMCHECKBOX  Other: FORMTEXT       Tissue Requested:  FORMCHECKBOX  Standard Care Core  FORMCHECKBOX  Core in addition to Standard Care Sample  FORMCHECKBOX  Core for research purposes only Sampling Instructions:  FORMCHECKBOX  As per Standard Care  FORMCHECKBOX  As per Study Protocol: Needle Size: FORMTEXT       Minimum # Passes: FORMTEXT       Minimum # Samples: FORMTEXT       OR Minimum Sample Size: FORMTEXT       Other:  FORMTEXT       Tissue Handling:  FORMCHECKBOX  As per Standard Care (lymphoma samples placed in saline, most others in 10% NBF)  FORMCHECKBOX  As per Study Protocol:  FORMTEXT       Supplies Provided by Study Team:  FORMCHECKBOX  No  FORMCHECKBOX  Yes: FORMTEXT       Tissue Disposition: IR staff to bring SOC samples to Surg Path (for routine processing & reporting). Study staff must pick-up all STUDY samples Indication:  FORMTEXT       Frequency:  FORMTEXT        FORMCHECKBOX  Other Imaging Exam/Procedure:  FORMTEXT       Indication:  FORMTEXT       Frequency:  FORMTEXT       ADDITIONAL REQUESTS  FORMCHECKBOX  Technologist Training:  FORMCHECKBOX  Web-based  FORMCHECKBOX  Onsite  FORMCHECKBOX  Travel to training site/meeting  FORMCHECKBOX  Time Required for Training:  FORMTEXT        FORMCHECKBOX  Site Certification Scan:  FORMCHECKBOX  Dummy or Volunteer Scan  FORMCHECKBOX  Phantom  FORMCHECKBOX  Other:  FORMTEXT        FORMCHECKBOX  Imaging Data Transmittal:  FORMCHECKBOX  CD  FORMCHECKBOX  Electronic by Study Team  FORMCHECKBOX  Electronic by Imaging Staff  FORMCHECKBOX  Other:  FORMTEXT        FORMCHECKBOX  Completion of Study Forms:  FORMCHECKBOX  Imaging Site Questionnaires  FORMCHECKBOX  Data Transmittal Form  FORMCHECKBOX  Exam Specific Worksheet  FORMCHECKBOX  Other:  FORMTEXT        FORMCHECKBOX  Advanced Image Post-Processing (image reformatting, quantitative analysis, etc.Exam Location(s):  FORMCHECKBOX  SMH Inpt.  FORMCHECKBOX  SMH IR  FORMCHECKBOX  East River Rd  FORMCHECKBOX  CC Ortho  FORMCHECKBOX  Penfield  FORMCHECKBOX  Red Creek  FORMCHECKBOX  Strong West  FORMCHECKBOX  GCHProtocol/Imaging Manual Attached?  FORMCHECKBOX  Yes  FORMCHECKBOX  No IF NO, provide description of exam(s) requested:  FORMTEXT      Completed form & attachments to:  HYPERLINK "mailto:RadClinicalTrials@URMC.Rochester.edu" RadClinicalTrials@URMC.Rochester.edu      CLINICAL TRIAL REQUEST FOR IMAGING SERVICES** **All imaging exams, procedures & reports will be transmitted to eRecord, My Chart & RHIO Rev. 5/1319 ؔڔܔ,.0DFbdf͚͵͵dM;#hBphIOCJOJQJ\^JaJ,jhBphIOCJOJQJU\^JaJ5j=hBphb[/5CJOJQJU\^JaJ5jH=hBphb[/5CJOJQJU\^JaJ5j<hBphb[/5CJOJQJU\^JaJ/jhBphIO5CJOJQJU\^JaJ&hBphIO5CJOJQJ\^JaJhIOCJOJQJ^JaJ hBphIOCJOJQJ^JaJԕ&:<϶ϧqbLq6q*h`CJOJQJaJ*jhb[/CJOJQJUaJmHnHu+j>hBphIOCJOJQJUaJhBphIOCJOJQJaJ%jhBphIOCJOJQJUaJ hBphIOCJOJQJ^JaJ#hBphIO5CJOJQJ^JaJh`CJOJQJ\^JaJ1jhb[/CJOJQJU\^JaJmHnHu,jhBphIOCJOJQJU\^JaJ2j>䴳ϴ^<>RTV`bҖݝyhPyB0#hBphIO5CJOJQJ^JaJhIOCJOJQJ^JaJ/j(@h%hb[/CJOJQJU^JaJ h%hIOCJOJQJ^JaJ)jh%hIOCJOJQJU^JaJh3hhIOOJQJ^JaJ&h`hIO>*CJOJQJ\^JaJ*jhb[/CJOJQJUaJmHnHu+j?hBphIOCJOJQJUaJhBphIOCJOJQJaJ%jhBphIOCJOJQJUaJҖԖ 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