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DXA Imaging Site Feasibility
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Please provide the following information regarding your DXA capabilities, equipment and technologists that you plan to use for this study.
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Fields marked with an "*" are mandatory.
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Study Information
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1) Please provide the trial information for the study that you wish to participate in. Enter, 'None', for general inquiry
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Protocol ID:
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Country:
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Primary Investigator Name:
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Primary Contact
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2) Please list the name, title and contact information for the person that will be the primary contact:
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*
Name:
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Title:
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Phone:
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*
Email:
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DXA EQUIPMENT
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3) Describe the relationship between your site and the recruiting site location (e.g. same office/floor/building/hospital complex, within 5 minutes drive, etc.):
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4) How many DXA systems do you have available, that can be used for this study? Enter a number:
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Number:
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System
# 1
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5) DXA System Manufacturer and Model(e.g. GE Lunar Prodigy, Hologic Discovery, etc.)
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Model:
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6) DXA System Software Version for the system checked above (e.g. 7.1, 9.2.3, etc.)
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Version:
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7) DXA Phantoms available for use (list all available):
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Specify:
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8) Does this DXA system have a current repair or routine service agreement?
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9) When was the last service performed on this system? Please describe the service.
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Date:
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Describe:
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10) Do you have any update/upgrade planned for this system? Please provide date or time frame.Please describe the upgrade/update.
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Date:
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Describe:
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11) Is this DXA equipment capable of performing/analyzing Bone Mineral Density (BMD)
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12) Do you routinely perform this type of study?
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#/week
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13) Please check the body areas that can be scanned:
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14) Is this DXA equipment capable of performing/analyzing Vertebral Fracture Analysis (VFA)?
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15) Do you routinely perform this type of study?
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#/week
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16) Is this DXA equipment capable of performing/analyzing Total Body Composition (TBC)?
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17) Do you routinely perform this type of study?
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#/week
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18) Please provide a copy of the calibration report for the past month for this system:
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19) DICOM storage capabilities?
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20) Image Export (please check all that apply)?
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Other:
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Image Upload/Electronic Form Completion
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21) Access to a computer to electronically upload images/forms to Imagepace?
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22) Broadband internet access on this computer?
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23) Does the internet have a firewall that restricts external internet access?
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24) Operating system on the computer is Microsoft Windows XP or later?
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If No, please specify:
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25) Microsoft Internet Explorer (6.0 or later) on the computer?
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26) Ability to burn a CD on this computer?
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Technologist
# 1
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Please complete the questions below, for each technologist at your site that will participate in this study.
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27) Technologist Contact Information
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Name:
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Work Phone:
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Cell:
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Fax:
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Email:
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28) Describe your employment at this site:
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29) What is your availability for this site?
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List days/time available
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30) DXA experience:
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Years:
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Months:
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31) BMD
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Estimate:# studies/week:
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32) Sites you routinely scan:
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33) VFA
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Estimate:# studies/week:
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34) TBC
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Estimate:# studies/week:
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35) Clinical trial experience:
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# of trials:
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36) Technologist Training:
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37) Technologist Certification:
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(please list all that apply and provide dates DD/MMM/YYYY)
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File Attachment
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38) Upload DXA system document. If you have multipe files, please zip the files first.If your file is larger than 15MB, please zip the file before upload.
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Attachment:
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