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Investigator Questionnaire
Use this form to submit your information in the Investigator Database. We will contact you when we have trials to match your capabilities and experience.

Fields marked with an "*" are mandatory.


Primary Contact


1) Please list the name, title and contact information for the person that will be the primary contact:

* Name:
Title:
Phone:
* Email:

Contact Address


2) Location

* Address 1:
Address 2:
Address 3:
* City:
* State:
* Postal:
Country:




3) Site Info

* Site Name:
* Site Fax:
* Site Email:
Web Site:




4) 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):


5) Are you affiliated with:

SMO (Site Management Organization) Network of Independant Sites Other (please describe below):


6) Additional Information if part of SMO or Network:

SMO/Network Name:
Contact Name:
Phone:
Email:
Fax:
Address:

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

Local Cental

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



9) *What is your therapeutic specialty?

*

10) *Please check each box that corresponds to the trials you have experience in:

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


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