Site Database Entry

Please enter your site information by filling out the below form. This will allow us to keep your site in mind for future studies.

Name of individual completing form (Contact)*

Contact Role/Title*

Email for Contact*

Phone for Contact*

Fax for Contact

INVESTIGATOR INFORMATION

Investigator First Name

Investigator Last Name

Degree

Therapeutic Area Specialty of Investigator

PI e-mail address

SITE INFORMATION

Institution's Name*

Type of Site*

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Site Address*

State*

City*

Zip*

Phone*

Fax

Preferred Method of Communication

SITE EXPERIENCE

Please list the types of trials/indications your site is interested in.*

How many clinical trials have been performed at your site in the past 3 years? (list number and phase)*

How many clinical trials are you currently conducting (list number and phase)*

SITE CAPABILITIES AND RESOURCES

Do you have a -80 Freezer?*

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Do you have a -20 Freezer?*

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If a study uses electronic data capture (EDC), can the study team accommodate this type of data collection?*

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Indicate what type of IRB your site uses*

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What is the usual turnaround time to obtain IRB approval for a clinical trial?*

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Are there any other approvals or reviews required to initiate the trial?*

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If yes to the above question, please describe.

SITE CONTRACT

What is the usual turnaround time to obtain an executed contract for a clinical trial?*

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Can you work on the contract in parallel to IRB submission?*

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Required review by financial committee?*

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SITE AUDITS

Has your site or team members at your site, been audited by the FDA?*

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If yes please provide a brief summary any findings:

Was there a 483 or other actions noted?*

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ADDITIONAL INFORMATION

Please provide any additional information as you feel would be helpful or relevant to this trial and your site:

Send me a copy of my responses

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