TrialMatch Listing Request Form

This form is intended for documentation of trial information and patient-/public-facing content for Alzheimer's Association TrialMatch. Complete all sections of this form and attach any required supporting documents. If you have any questions about the listing request process, please call 872.249.0282 ext. 2269 or email us at TrialMatch@alz.org.

Date of Submission*

Study Title/Headline*
This will be the header in search results

Section 1: Requestor Information
Provide the following information about the requestor. This information will not be visible to the patient/public and will only be used for following up on this request.

Name*

Telephone*

Email Address*

Organization*

Requestor's Position*

Section 2: Type of request
Provide the following general information about the request. This information will not be visible to the patient/public and will only be used for processing the request.

Is this a new study?*

Yes No

Is this a new study site?*

Yes No

Is the study IRB approved?*

Yes No

Evidence of IRB approval

Is the study registered on clinicaltrials.gov?*

Yes No

Section 3: General Study Information
Provide the following general information about the study. This information will be visible to the patient/public and will also drive Search Engine Optimization.

Official study title*

Protocol ID number(s)*
Please include a protocol ID, as IRB number or grant number. Your protocol ID will serve as your unique identifier on TrialMatch.

Name of study sponsor*

Name of principal investigator*

Phone number of principal investigator*

Other description

Link to study, if online

Can your study be completed remotely?

Yes No

Is your study available in Spanish?

Yes No

Phase (if appropriate)*

Status*

Recruiting Not recruiting

Brief description of study*

Detailed study description*

Study start date
Choose the estimated recruitment start date. If recruitment has already started, leave blank.

Study end date*
Choose the estimated recruitment end date.

Section 4: Study Site Information
Provide information about the study site(s). This information will be visible to the patient/public and will also drive Search Engine Optimization.

Primary site name*

Primary site address*

Contact name*

Contact email*

Contact Phone*

Additional sites?*
Information for additional sites will be requested at time of listing approval.

Yes No

Section 5: Eligibility
Provide the following information about participant eligibility for the study. This information will be visible to the patient/public and will also drive Search Engine Optimization.

Appropriate conditions*
Input all appropriate conditions. If multiple, delimit with commas.

Is this study open to healthy volunteers?*

Yes No

Minimum age*

Maximum age*

Eligible Gender(s)*

Other eligibility criteria*

Section 6: Additional Information
Provide additional information about the study. Some of this information may be visible to the patient/public and will also drive Search Engine Optimization.

Study schedule*
How many visits/sessions? How long are the visits? Time between visits? Etc.

Study activities may include:*
E.g. answering questions over the phone, receiving an infusion once a month, taking a medication by mouth daily, exercising twice weekly, using a device, etc.

Additional details, if any

Send me a copy of my responses

Email address

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