Investigator Information
Thank you for your time and interest. Please complete the following form. You may also print a copy of this form and fax it to 301-294-4561/6338.
Name:
M.D.
Ph.D.
Last:
First:
Middle Initial:
Area of Specialty:
Sub-Specialty:
Institution:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Country (if outside U.S.):
E-Mail:
Phone Number:
Fax Number:
RESEARCH STAFF- CRC
Title:
RN
NP
PA
MD
Ms.
Mrs.
Mr.
Last Name:
First Name:
Middle Initial:
Telephone Number:
Fax Number:
Email:
RESEARCH EXPERIENCE
Do you have experience in conducting clinical trials?
Yes
No
Did you recruit the required number of patients in the previous trial?
Yes
No
Do you have the staff to conduct a clinical trial?
Yes
No
Does your staff have experience in conducting clinical trials?
Yes
No
Do you have a database of eligible patients for a clinical trial?
Yes
No
Can you use Central IRB?
Yes
No
