Data Set Name (required)

PI (required)

Date of Report
Short Name (required)

IRB/Ethics Committee approved date:
Ethics Committee ID:
Grant number/ID:
Principle Investigator (required)

Other Team Members

Email (required)

Phone Number:

List all Study Team Members with Emails

Summary of NIX Data
Please include the source of the data, eligibility/inclusioncriteria, and the data elementsto be captured.Please attach imaging protocols used. Be sure to specify the imagingmodality(s)and thesize of the dataset.Additional Eligibility information. Note who has ownership of the data and what permissions will be needed.Data elements maybe information about the patients age, sex, blood tests, imaging information or any relevant diagnostic information

Overview (1-2 sentences summary of dataset):

Funding Source:

Source of data(clinical trial, sites involved, central node):

Data ownership (owned by PI/shared/obtained elsewhere):

Data ownership and permissions:

Permissions (access for other members):

Overall study status:
-Completed study/ongoing/discontinued study:

Eligibility/Inclusion criteria overview:

Current number of patients/scans:

Planned number of patients/scans:

Data elements to be captured through review:

Imaging modalities:

Disease types and sites:

Treatment Types:

Annotations and analysis already performed:

Protocol deviations if any, and actions taken:

Time constraints associated with sharing your dataset if any:

Potential Benefits to NIX