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Phone: 03 9905 0100 [email protected]

PRECLINICAL MEDISO PET CT SCANNER ACCESS FORMLocated at Room LA44, AMREP, Prahran

PQMS3-MBI-FRM-P004-V1

Section 1 Project Details

Project title ..................................................................................................................................

.......................................................................................................................................................

Project aims ................................................................................................................................

.......................................................................................................................................................

.......................................................................................................................................................

.......................................................................................................................................................

Chief investigator .......................................................................................................................

Proposed study start date/ completion date:...........................................................................Have you already used any MBI facilities for this project?

NO YES

If yes, what is the MBI Project Number of the existing project? ...................................................

Finance details (person responsible for funding the studies)

Full name (person responsible for funding the studies)School/Centre/DepartmentFaculty / InstituteUniversity / OrganisationEmailTelephone

OR, if from Monash University, please provide a fund number and cost code for charges

Cost Code ............................................ Fund number ................................................................

Finance officer in charge of this account ......................................................................................

End date of research contract …………........................................................................................

Project funding details: please specify the source and end date of grant or research contract funding for this project (e.g. NHMRC project grant, contract research)

.......................................................................................................................................................

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Preclinical Mediso PET CT Scanner Access Form PQMS3-MBI-FRM-P004-V1 Page 1 of 6Date of issue: 08/06/2016

Printed copies of this document are uncontrolled copies. For current versions refer https://confluence-vre.its.monash.edu.au/


Section 2 SamplesSubstances/tissues to be scanned ...........................................................................................

☐ Living ☐ Ex vivo ☐ Non biological

Approximate size of samples .........................................................................................................

Approximate number of samples ..................................................................................................

Desired resolution (if known): ........................................................................................................

Identify any hazards associated with your samples or associated experimental procedures:Tick all that apply

Hazardous Substances/Dangerous Goods Biological*Explosive BacteriaGas VirusFlammable/combustible Human tissue/cells/fluidOxidiser or organic peroxide Animal tissue/cells/fluidCorrosive Genetically modified organisms (GMOs)Radioactive substance Allergenic substancesToxic Substance / Cytotoxin Zoonotic (infectious) agentsCarcinogen / mutagen / teratogen Hazardous proteins/peptidesDrug (e.g. anesthesia) Mechanical/EquipmentIrritant/Harmful Electrical equipment/toolsSensitising agent Non ionising radiation (e.g. laser)Dusts/fibresNanoparticles Other HazardsEnvironmental pollutant .

*Please indicate if biological samples are ‘fixed’ (i.e. infectivity is reduced). This may be via the use of aldehydes, alcohols, picrates, mercurials, oxidising agents etc.

If you have ticked any of the above, or have any other hazards which apply, please describe the hazard and what safety precautions you will implement along with the appropriate Risk assessments and SOP’s.

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Section 3 Modalities to be used

3.1 Does the project require use of PET?NO Please proceed to 3.2

YES Please specify the radioisotope being used…………………………………………………...

This must be discussed with the Radiation Safety Officer before use.




3.2 Does the project require use of CT?NO YES

Section 4 Animal ethics approval and holdingDoes the project use live animals?

NOYES, and I have provided:

a Monash University Animal Ethics Committee approval number, and/oran AMREP Animal Ethics Committee approval number, anda copy of the AEC approval (and approval of any amendments), anda copy of the original application (and any amendments) with this form.

Section 5 Investigators For every investigator who will be present during the scans, and the Chief Investigator, please provide the following information (copy and paste additional entries, if required)

5a) Investigators - ALL Monash Staff and Students Please Use This SectionExternal users, please provide investigator information on next page.

Investigator #1:First name: ......................................................Surname: ...................................................Title: ....................

Email: ............................................................................................ Phone: ....................................................

Institution: ....................................................... Department: .......................................................................

Mailing address: ...............................................................................................................................................

……………………………………………………………………………………………………………………………

Staff /Student Number: ..................................... Authcate name: ..................................................................

Position: Staff (please specify e.g. research assistant, post doc) Student (please specify e.g. honours, PhD)

This investigator has completed:AMREP animal house induction training - completed on__________________

A copy of evidence of this training is attachedMonash University, Baker IDI or Burnet Institute (circle as appropriate) radiation training

- completed on ____________________A copy of evidence of this training is attached

Individual user radiation license (Department of Health) expires on ____________A copy of this license is attached

Radiation handling training for long half-life PET radioisotopes.PET/CT operator training certified on ____________Radiation Badge (TLD) No. ______________




Investigator #2:First name: ......................................................Surname: ...................................................Title: ....................

Email: ............................................................................................ Phone: ....................................................


Mailing address: ...............................................................................................................................................

……………………………………………………………………………………………………………………………

Staff/Student Number: ...................................... Authcate name: ..................................................................



A copy of evidence of this training is attachedMonash University, Baker IDI or Burnet Institute (circle as appropriate) radiation training

- completed on ____________________A copy of evidence of this training is attached


Radiation handling training for long half-life PET radioisotopes.PET/CT operator training certified on ____________Radiation Badge (TLD) No. ______________

5b) Investigators - NON Monash staff and students please use this sectionMonash users, please provide investigator information on previous page.(copy and paste additional entries, if required)Investigator #1:First name: ......................................................Surname: ...................................................Title: ....................

Email: ............................................................................................ Phone: ....................................................


Mailing address: ...............................................................................................................................................

……………………………………………………………………………………………………………………………



A copy of evidence of this training is attached




AMREP radiation training - completed on ____________________A copy of evidence of this training is attached


Radiation handling training for long half-life PET radioisotopes.PET/CT operator training on ____________Radiation Badge (TLD) No. ______________




Section 6 Data collection and storageRaw imaging data collected from each scanner is typically archived on a central Monash University server system called “MyTardis”. This server includes a web-based access controlled system to view and download your files and is free for all MBI users.

Who has access to my data? Only users specified on this form will have access to your specific data folders. Note: All pre-clinical data generated at MBI on MyTardis is accessible by the head of pre-clinical imaging, the director and the facilities manager at MBI and certain Monash IT staff members.

Do you wish to use MyTardis? ☐NO ☐YESIf YES please specify names and email of the people you wish to access the data via the web server.

MBI Project number access: Access to all your research group’s imaging data.

Name: .............................................................Email: ...................................................... Authcate: .............


User folder access: Access to only the specific user’s imaging data (not required if listed above)





If NO: Contact the head of pre-clinical imaging directly or via email to ([email protected]).

Section 7 Summary of Terms and ConditionsFull details of the terms of conditions of use for the Mediso PET/CT are at https://platforms.monash.edu/MBI > Forms and Policies > MBI Policies (policy number 1). By signing this agreement the chief investigator agrees to these terms in full.

Key user responsibilities are listed below:

1. Acknowledge MBI for provision of the Mediso PET/CT in your research outputs, including in the acknowledgements section of scientific publications

2. Provide a copy to MBI of scientific publications arising from use of the Mediso PET/CT.3. Pay the hourly costs associated with use of the Mediso PET/CT as detailed in this application and

found by clicking here or at https://platforms.monash.edu/MBI > Facilities > Prices.4. Chief investigator will ensure staff and students working on the project will follow all MBI and AMREP

occupational health and safety and radiation requirements on site.

Section 8 Chief Investigator Agreement

As chief investigator of this project I agree to abide by the terms and conditions as outlined at https://platforms.monash.edu/MBI > Forms and Policies > MBI Policies (policy number 1). and approve data access for researchers listed on this form.

Signed:.................................................................... Date: ________ / ________ / _______

Name: .....................................................................

Please return this completed form via email to ([email protected])



mailto:[email protected]

https://platforms.monash.edu/MBI


https://platforms.monash.edu/mbi/index.php?option=com_content&view=article&id=90&Itemid=203


mailto:[email protected]

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