SCCR Intake Form

Thank you for your interest in partnering with Stanford Center for Clinical Research (SCCR). The following questions will inform SCCR of your study needs. Please complete this form with as much information as you have available at this time. An SCCR team member will contact you via email in less than 5 business days to schedule a follow up conversation for a broader understanding of your project needs. We look forward to meeting with you soon!

DO NOT USE:Initial entry date

mm/dd/yyyy

Name of person completing form

(First & Last Name )

Email of person completing form

Are you part of the Stanford community?

Yes (Stanford Affiliated)

No (External Collaborator)

What department or division is your team affiliated with?

Who is the Prinicipal Investigator for this study?

Who is the Faculty CRU Reviewer for this project?

Have you worked with SCCR before?

Current Partner / Staff

New Partner

Does this require a meeting with Intake Staff?

What is the title of your project?

Please upload any supporting documents you may have to help us support our assessment:

(i.e.: Protocol, ICF, Budget, Contract, NDA)

Drop your files here

Please share a short description of your study here:

What type of project is your study?

Interventional Drug / Device / Biologics

Observational Registry

Observational other

Other

Who is sponsoring this trial?

What therapeutic areas does your study involve?

Have you already submitted this protocol to the IRB?

Yes

Please comment on the status of the IRB submission

Have you already submitted this protocol to RMG?

Yes

Please comment on the status of the RMG submission

What is the funding source for this project?

(Select all that apply)

Industry

Federally Funded

Other (Department Funds, Gift Funds, etc)

None

Please comment on the status of your funding

What is your expected Study Start date?

mm/dd/yyyy

What is your expected Study Stop date?

mm/dd/yyyy

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