fMRI: User Form

User Form

Form Info

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Upload Files

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Review & Confirm

Section 1: Contact Information

Research Assistant/Coordinator:
Phone:	Uniqname: *

Grant Administrator/Billing Contact:
Phone:	Uniqname:

*These email address will be added to email group, fmri.users@mich.edu, unless otherwise requested.

Section 2: Project Information

Please upload a copy of your IRB Approval & Consent Form on the next page.

IRB Approval No: Exp: HUM00012345	IRB Approved Title:
IRB Approval Date: Format: mm/dd/yyyy	IRB Expiration Date: Format: mm/dd/yyyy

Expected Number of Scans Per Year:	Length of Time for Each Scan:
Are you a first time user of our facility?	Is this a children's study?
What and how many peripherals will be required for your study? (i.e. goggles, pain devices, claw, etc.)
Is physio collection required?	Is DTI collection required?
Do you have any other special requirements? (i.e. special population needs, scheduling requirements, etc.)

Section 3: Billing Information

Please include parent grant if sub-account is not yet created.

Funding Start Date: Format: mm/dd/yyyy			Funding End Date: Format: mm/dd/yyyy
Shortcode: Exp: 012345	Fund: Exp: 10000	Dept. ID: Exp: 250700	Prog: Exp: 12345	Class: Exp: 12000	PG: Exp: F012345