ࡱ> a bjbj 4hGbhGb 4TTTTThhh8|DhI#`:"" """""""$$'^"T"TT#vTT"" $!>yVC!"#0I#! (Z ($! (T$!""7NI# (B : CISC Costing Ref. No. .... Brighton & Sussex Medical School Clinical Imaging Sciences Centre Request for Scanning Services (July 2019 V20) SECTION 1: To be completed by applicant prior to submitting grant application. Name of Applicant & Name of Budget holder (and email address / phone)School / DepartmentResearch Project TitleSource of Funding and Budget Code (for billing)Specify (e.g. Medical Research Council)If Commercial, Name of Source and level of scanning funds applied or expected to be applied forTotal Value of Grant secured or applied for in respect of this specific project ()pFACT Number (if known)Requested Start Date for ScanningRequested End Date for ScanningNo of Pilot Scans / Hours requested (Application must be made to CISC Academic Director)Modality of Scanning RequiredfMRI / MRI / PET CT / CTUse of Scanner Required3T MRI / 1.5T MRI / PET CT / CTTotal number of scanning hours for project Remember you are billed for the amount of time your participant is in the scanner room. Note: Please ensure you build in an allowance for late cancellations etc, that can incur charges)No of Hours Required by academic year (August - July) Please specify. Note: Scanning costs exclude any reporting2019 / 202020 / 212021 / 222022 / 232023 / 242024 / 252025 / 262026 / 27Frequency of scanningHow many Subjects being scanned will require Contrast Agent / MediaType of Contrast Agent / Media requiredPlease indicate who will provide Contrast Agent / Media. Note: If provided by CISC this will incur additional costs Will the project require any out of normal hours (09.00 17.30) scanning or medical cover. If Yes, please provide full details. Please note out of hours medical cover may incur an additional charge  Signed: Date: Name: Position: Send to: Stuart Welling Business Director CISC, BSMS, AVƵ, Falmer, BN1 9RR. Email to:  HYPERLINK "mailto:S.Welling@bsms.ac.uk" S.Welling@bsms.ac.uk cc to:  HYPERLINK "mailto:sjw@cooden.plus.com" sjw@cooden.plus.com And to:  HYPERLINK "mailto:research_support@sussex.ac.uk" research_support@sussex.ac.uk to ensure that correct costs are reflected in the research grant application and there is an auditable record on the project file) SECTION 2: Costing for CISC Use Type of Scans  No of Hours  Cost per hour  Contrast Media per scan  Other Costs per scan  Total Cost Per hour  Total Cost fMRI / MRI2019 / 202020 / 212021 / 222022 / 232023 / 242024 / 252025 / 262026 / 27Total Type of Scans No of Hours  Cost per hour  Contrast Media per scan  Other Costs per scan  Total Cost Per hour  Total Cost PET CT / CT2019 / 202020 / 212021 / 222022 / 232023 / 242024 / 252025 / 262026 / 27Total Costing Prepared by CISC Business Director Name: Stuart Welling Signed: Date: Notes: The charges are guaranteed once the costing has been supplied to the applicant providing the scanning occurs according to the timeframe set out in the application. 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