Cooperation application form

Contact information

Applicant:* 
Institution:* 
Address:* 
E-mail address (only one valid e-mail 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)
BIL staff needed for measurements:
BIL staff needed for processing/statistics:
BIL animalarium housing + anaestesia needed:
Summary (importance to the field):* 
Materials and methods:
(including which MR sequence/BLI needed)

Publishing policy

Will the study or any part thereof be published:
If so, provide provisional author list: 
Is imaging a large part of the envisioned publication:

Data and IP management

The Bio-Imaging Lab needs to take responsibility of storing the data:
IP protection:

Patent numbers if protected:

Funding:
In case of a mutual project: project type: 
funds can be used for (salaries, goods, services, ...) 
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.
*  required fields
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 these personal details for internal project screening purposes only. Under no circumstances will these details be given to third parties. If you want to change your personal details or have them removed from our database, please inform us using the address above. More information about our privacy policy: www.uantwerpen.be/disclaimer.