Cooperation application form

Contact information

Applicant *
Institution *
Address *
Email address (only one valid email address) *
Tel *

Introduction
Feasibility study only?
(Any larger study also starts with a feasibility study. Please indicate here whether you request a short study only or wish to start a lager project. Short is defined as limited to 2 days' scanning, performed by BIL staff)
Anticipated start of cooperation *(dd/mm/yyyy)
Anticipated end of cooperation (dd/mm/yyyy)
Aim *
Hypothesis
Novelty
3 relevant publications (PMID only)

3 own and related publications (PMID only)

Study design
Type of subjects (which animal/item)*
Condition
Number of subjects (su)
Number of time points at which to measure (t)
Number of scans at each time point (sc):
(total number of scans = su x t x sc)
MICA/BIL staff needed for measurements
MICA/BIL staff needed for processing/statistics
MICA/BIL animalarium housing + anaestesia needed
Summary (importance to the field) *
Materials and methods
(including which MR sequence/BLI/Tracer needed)

Publishing policy
Will the study or any part thereof be published
Is imaging a large part of the envisioned publication

Data and IP management
The MICA/BIL facility needs to take responsibility of storing the data
IP protection
Patent numbers if protected
Funding
Other comments

The content of this form is intended for internal project screening purposes only, the content will not be shared with third parties.
Futhermore, submitting an application does not a guarantee that the project will be accepted by the Bio-Imaging Lab.
Submit
The Bio-Imaging Lab, Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, Campus Drie Eiken, Building UC, Universiteitsplein 1, B-2610 Antwerpen, Bio-Imaginglab@uantwerpen.be is collecting this personal data for internal project screening purposes only. Under no circumstances will your contact details be passed on to third parties. This data will be stored until the cooperation has been completed. If you would like to view, limit, change or remove your personal data, please send an email to the address above. More information about our privacy policy: www.uantwerpen.be/disclaimer.