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Radiological Services Request (RSR), page 1
Basic · 44/100Form Complexity Index

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What this form asks for

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The Radiological Services Request (RSR) is a mandatory form for Principal Investigators at UCD Health who need to use the Department of Radiology's services for clinical research. Submitting this form initiates a review by the Radiology Research Committee to determine the scope and cost of the requested support. Today, this form can be filled out quickly and accurately using AI-powered services like Instafill.ai, which can also convert non-fillable PDF versions into interactive fillable forms.
Fillable fields50
Pages2
Sections22
Form Complexity IndexBasic, 44/100

The AI checks your answers before you download

14 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Validates Contact Person Email Format

This check ensures that the value entered in the 'Contact Person Email' field follows the standard email format (e.g., [email protected]). This is critical for ensuring that communications regarding the request can be successfully delivered to the contact person. If the format is invalid, the form submission will be rejected with a message prompting the user to enter a valid email address.

Validates Contact Person Phone Number Format

This check verifies that the 'Contact Person Phone #' field contains a valid phone number, conforming to a standard format like (XXX) XXX-XXXX or XXXXXXXXXX. Correctly formatted phone numbers are essential for direct communication if email is unresponsive or for urgent matters. A validation failure would prevent submission and ask the user to correct the phone number.

Ensures Project Dates are Chronological

This validation confirms that the 'Estimated project end date' is on or after the 'Estimated project start date'. This prevents logical errors in project planning and scheduling. A project cannot end before it begins, and enforcing this logic at the point of entry maintains data integrity. If the end date is before the start date, an error message will be displayed.

Ensures Mandatory Project Identifiers are Complete

This check verifies that the 'Principal Investigator', 'Study Title', and 'IRB#' fields are not empty. These fields are fundamental for identifying, tracking, and processing the research request within the UCD Health system. Failure to provide this information would make the request ambiguous and unprocessable, so the form cannot be submitted until they are filled.

Validates Anticipated Patient Count

This check ensures that the 'Anticipated # of total patients' field contains a positive integer greater than zero. This number is crucial for resource planning, estimating costs, and understanding the scope of the study. A non-integer, zero, or negative value is illogical and would cause a validation failure, requiring the user to input a valid whole number.

Requires at Least One Research Procedure Selection

This validation ensures that at least one of the research procedure checkboxes (e.g., CT, MRI, X-Ray) has been selected. A request for radiological services is meaningless without specifying which services are needed. If no procedures are selected, the form submission will be blocked, and the user will be prompted to select at least one procedure.

And 8 more checks
  • Ensures Scan Count for Selected Procedures
  • Validates Presence of Billing Account Number
  • Ensures Exclusive Selection for Tracer Supply
  • Ensures Exclusive Selection for CRC Support
  • Validates Mutually Exclusive Radiologist Interpretation
  • Ensures Project Start Date is Not in the Past
  • Validates Internal Supervisor Date Format
  • Ensures Signature and Date Co-dependency

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How to Fill Out RSR Online for Free in 2026

What the AI walks you through.

  1. Navigate to Instafill.ai and upload or select the Radiological Services Request (RSR) form.
  2. Use the AI assistant to automatically populate requesting department information, such as the Principal Investigator's name, contact details, and department.
  3. Enter key project details, including the study title, protocol number, IRB number, and estimated start and end dates.
  4. Specify the research procedures required by checking the relevant boxes (e.g., CT, MRI, X-Ray) and entering the number of scans per patient for each.
  5. Indicate technical requirements, such as whether a UCDH radiologist interpretation is needed or if a tracer is supplied by the study sponsor.
  6. Add any special requests or notes in the provided text field.
  7. Review all the information populated by the AI for accuracy, make any final adjustments, and then download or submit the completed RSR form.

Common Mistakes in Completing RSR

The ones the AI is built to catch.

Incomplete Procedure Request Details
Users often check a box for a requested procedure like 'CT' or 'MRI' but forget to fill in the corresponding '(# of scans per pt.)' field. This happens due to oversight while quickly completing the form. Without the number of scans, the Radiology Research Committee (RRC) cannot generate an accurate cost estimate or plan for resource allocation, leading to delays. To avoid this, carefully review each requested procedure and ensure both the checkbox and the number of scans are filled out. AI-powered tools like Instafill.ai can flag these incomplete pairings to ensure all required information is provided before submission.
Mismatched Study Title or Protocol Number
The form requires the 'Study Title (per Protocol)' and 'Protocol Number', but applicants sometimes enter an abbreviated title, a working nickname, or an outdated protocol number. This discrepancy makes it difficult for reviewers to match the request with the correct protocol and IRB documents, causing processing delays and potential rejection. Always copy the title and protocol number directly from the final, approved protocol document to ensure accuracy. Using a form-filling tool can help store and populate this official information consistently across all related documents.
Incorrect or Missing Billing Account Number
The 'DAFIS/Acct to Invoice' field is critical for billing, but it is frequently left blank, or an incorrect or expired account number is entered. This mistake halts the financial approval process and can prevent the study from starting until the correct billing information is provided and verified. Before submitting, confirm the active and correct DAFIS or account number with your department's financial administrator. AI tools can help validate the format of such numbers and prevent submission with a blank critical field.
Omitting Required Documents on Initial Submission
The instructions clearly state that the initial submission must include the completed RSR Form, the Protocol, and Imaging Acquisition Guidelines. A common error is to email only the RSR form, assuming other documents will be requested later. This incomplete submission will be put on hold until all required documents are received, delaying the 14-day review timeline. To prevent this, create a checklist and ensure all specified documents are attached to the initial submission email.
Confusing the Initial Submission with the Study Startup Email
The workflow has two distinct email steps: an 'Initial Submission' for review and a later 'Email to establish Study Startup' after IRB approval. Researchers mistakenly believe the initial submission is the only step, and they fail to send the follow-up email with the final IRB approval and signed RSR Estimate. This failure prevents the RRC from scheduling the mandatory study startup meeting, effectively stalling the project. Carefully read the instructions and set a reminder to send the second notification once IRB approval is secured.
Ambiguous Radiologist Interpretation Request
When specifying if a 'UCDH Radiologist Interpretation' is required, users may check 'Yes' without selecting the specific type (Special, Dynamic, RECIST) or check conflicting options. This ambiguity forces the RRC to seek clarification, delaying the estimate. Be specific about the interpretation requirements as defined in your study protocol. If you are unsure, consult with the PI or the study sponsor before completing this section.
Using an Informal or Incorrect Contact Email
The 'Contact Person Email' is the primary channel for all communication, including the RSR Estimate and scheduling requests. Providing a personal email, a misspelled address, or the email of a person who is not actively monitoring the project can lead to missed deadlines and critical communications. Always provide an official, regularly monitored institutional email address for the designated contact person to ensure timely correspondence.
Leaving 'Special Requests/Notes' Blank When Necessary
Researchers may have specific needs not covered by checkboxes, such as non-standard imaging sequences, specific timing for dynamic scans, or patient scheduling constraints, but they neglect to detail them in the 'Special Requests/notes' field. This omission can lead to incorrect scheduling, improper image acquisition, and unusable data. Use this field to communicate any and all study requirements that deviate from standard procedures to ensure the radiology team is fully prepared.
Forgetting to Specify Tracer Supply Status
For PET and Nuclear Medicine studies, the question 'Is Tracer supplied by Study/Sponsor?' is crucial for budgeting and logistics, yet it is often left unanswered. The cost and sourcing of radiotracers are significant, and failing to specify this information prevents an accurate cost estimate. Always select 'Yes', 'No', or 'Not Applicable' to avoid delays while the RRC seeks clarification. Since this form is a non-fillable PDF, a tool like Instafill.ai can convert it into a fillable version, making it easier to see and complete all required fields, including these radio buttons.

Frequently Asked Questions About RSR

 

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Yes. You pay $0 today. Cancel before Nov 7 and you are never charged. Keep it, and it is $19.99 a month for 5 fills of your RSR.
Can I fill other forms too?
This plan is for your RSR: your own AI agent fills it as often as 5 times a month. To fill other forms and upload your own, choose a Professional plan from your account.
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From your account, in two clicks, any time. No email, no call.
How does the AI fill out RSR?
You answer a few questions in plain words, or upload a document you already have. The AI reads what you give it and puts each answer into the right field of RSR, on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.
What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is RSR to fill out?
RSR has a Form Complexity Index of 44 out of 100, in the basic tier: 50 fillable fields across 2 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is the purpose of the Radiological Services Request (RSR) form and who needs to fill it out?
The RSR form is mandatory for any clinical research at UCD Health that requires support from the Department of Radiology. It must be completed by the Principal Investigator (PI) or their Clinical Research Coordinator (CRC) before conducting the research.
What documents do I need to submit with my initial RSR form?
Your initial submission must include the completed RSR form, the study protocol, any available Imaging Acquisition Guidelines, and a copy of the Billing Grid or Medicare Coverage Analysis (MCA).
How long will it take for my RSR form to be reviewed?
The Radiology Research Committee (RRC) will review your submission and provide either an Exemption or an RSR Estimate within 14 days of receipt. The form notes that urgent requests will be considered.
Where do I send the completed RSR form and all the required documents?
All research procedure request packets, including the RSR form and supporting documents, must be submitted via email to [email protected].
What do I need to do after my study receives final IRB approval?
After receiving final IRB approval, you must send an email notification to the RRC. The RRC will then contact you to schedule a study start-up meeting.
What is the difference between an 'Exemption' and an 'RSR Estimate'?
If the RRC determines your study has no research-only procedures, it will be granted an Exemption. If it does involve research-only procedures, you will receive an RSR Estimate detailing the costs and requirements.
Who is responsible for de-identifying and sending study images to sponsors?
The form states that it is the responsibility of the Investigator or the research team to obtain, de-identify, and transmit images to sponsors. This is not a service provided by the Radiology department.
Where can I find the research rates for the radiological services I am requesting?
The current research rates for radiological services are posted on the UCD Health website at https://health.ucdavis.edu/radiology/research/rates.html.
What information should I enter in the 'DAFIS/Acct to Invoice' field?
This field requires the specific DAFIS or Account number that the Department of Radiology should use for invoicing the costs associated with the requested research services.
Can I use an AI tool to help me fill out this form?
Yes, you can use services like Instafill.ai, which leverage AI to accurately auto-fill form fields from your saved information, helping you save time and reduce potential errors.
How can I fill out the RSR form online?
To fill out the form online, you can use a service like Instafill.ai. Simply upload the PDF, and the platform will make it an interactive, fillable form that you can complete and save digitally.
The PDF version of the RSR form I have is not fillable. What should I do?
If you have a non-fillable or 'flat' PDF, you can use a tool like Instafill.ai. It can convert the document into an interactive, fillable form online, making it easy to complete.
What does the 'UCDH Radiologist Interpretation Required' section mean?
This section is for specifying if a UCDH radiologist needs to officially read and interpret the scans for your research. You can select 'Yes', 'No', or specify a special interpretation type like RECIST.
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