INVESTIGATOR BACKGROUND

The Investigator Background form gives us an opportunity to learn more about your research experience and interests. We will direct clinical trial opportunity notices to you based on the information provided. Be sure to include areas of research experience and areas which you wish to explore. Fill out the form below to begin.


Key Benefits

  • Allow us to direct clinical programs of interest to you.

  • Allow us to submit information to Sponsors, that require immediate attention, on your behalf

  • Identify areas where we can promote your research

  

 

 

 

  

 

Investigator Background Form

Name
Degree(s)
Site Name
Address
E-mail
Phone 
Fax 

Medical Specialty

Coordinator Name

If you do not have a coordinator, would you be willing to contract with us to provide one?
Yes  No

Can you work under the umbrella of a Central IRB? Yes  No

Type of Practice

Solo

Group

Multi-Specialty

Research Only

Hospital

University
Please indicate your clinical trial experience or interest. Click all that apply.
Pre-Clinical Phase I Phase II Phase III Phase IV
Do you have access to the following equipment? Click all that apply.
ECG   Centrifuge  Fridge (2-8°C)
Freezer (-20°C) Refrigerated Centrifuge Internet
Freezer (-70°C) On-Site Lab Dexa Scanner
Ultrasound  X-Ray MRI
Ophthalmologist EDC experience IVRS experience
Ability to draw, prepare and ship blood and specimen samples
Secure controlled area with limited access and locked for IND
Quiet room for coordinator/monitor to work

Research Experience/Interest:
Please note all areas of experience/interest from the following list. Check all that apply. Leaving it blank indicates no research experience or interest in that area/indication. Press CTRL and click to make multiple selections per category.

Neurology  Adult Adol. Child
Psychiatry Adult Adol. Child
Oncology Adult Adol. Child
Cardiovascular Adult Adol. Child
Gastroenterology  Adult Adol. Child
Sexual Dysfunction  Adult Adol.
Sleep Disorder Adult Adol. Child
Pain Management Adult Adol. Child
Endocrinology Adult Adol. Child
Pulmonary Adult Adol. Child
Infectious Disease Adult Adol. Child
Dermatology Adult Adol. Child
Surgery  Specify:

Adult Adol. Child

Other areas of experience/interest:

       
 
 
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Last modified: September 18, 2009
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