Medpace.com::Investigator Questionnaire

Investigator Questionnaire

Use this form to submit your information in the Investigator Database.

Fields marked with an "*" are mandatory.

*Legal Site Name:
*Street:
(please include suite, building, room number if applicable)
*City:
State / Province:
*Postal:
Country:
*Main site phone:
*Main site fax:
*Main site email address:
Website:

Type of Site (check one):
Combined Private Practice and Research Site Clinical Research Site (Patients not treated outside of clinical research studies) Private Hospital-based Site University/Academic-based Site Government Institution Site Other (please describe below):

Are you affiliated with:
SMO (Site Management Organization) Network of Independant Sites Other (please describe below):

Additional Information if part of SMO or Network:
SMO/Network Name:
Contact Name:
Phone:
Email:
Fax:
Address:

What type of IRB/Ethics Committee can your site utilize?
LocalCentral

Please complete the following for each investigator at your site (first & last name, title, Medical/Therapeutic Specialty):


*What is your therapeutic specialty?

*Please check each box that corresponds to the trials you have experience in:
Allergy	Hormone Replacement Therapy
Angina	Hyperlipidemia
Anxiety	Hyperlipidemia, Familial
Arrhythmia	Hypertension
Arthritis	Interventional Cardiac & Vascular Procedure
Asthma	Irritable Bowel Syndrome
Atrial Fibrillation	Metabolic Syndrome
Benign Prostatic Hyperplasia	Movement Disorders
Cardiovascular Device	Obesity
Cerebrovascular Event (acute)	Oncology
Cerebrovascular Event (outpatient)	Osteoporosis
Chronic Obstructive Coronary Disease	Otitis Media
Congestive Heart Failure	Overactive Bladder
Coronary Artery Bypass Graft	Pain Management
Coronary Artery Disease (acute/inpatient)	Parkinson's Disease
Coronary Artery Disease (outpatient)	Pediatric Diabetes
Depression	Pediatric Hypercholest- erolemia
Diabetes Type I	Pediatric Hypertension
Diabetes Type II	Peripheral Vascular Disease
Diabetic Nephropathy	Phase I Unit
Diabetic Neuropathy	Psoriasis
Diabetic Retinopathy	Rheumatoid Arthritis
End Stage Renal Disease	Rosacea
Erectile Dysfunction	Sexual Dysfunction
Fibromyalgia	Sexually Transmitted Disease
Gastroesophageal Reflux Disease	Smoking Cessation
Growth Hormone Abnormalities	Thyroid Disorders
Headache/Migraine	Ulcerative Colitis
Women's Health Studies
Other (list):

Thank you very much for your time. Medpace will use this information when considering investigators for future trials.

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