Investigator Questionnaire

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

Legal Site Name*

Address*

Street Address (Please include Suite, building, room number if applicable) City State / Province / Region ZIP / Postal Code 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

Are you affiliated with?

SMO (Site Management Organization)
Network of Independant Sites

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?

Local
Central

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:*

For Investigators outside of the U.S.:
By submitting information on this webpage to Medpace, I am consenting to the collection and transfer of my personal data out of the country where I reside. I have read Medpace’s privacy policy https://www.medpace.com/privacy-policy/ and understand that under the law of the EU and some other countries, I have the right to access, modify or delete personal data, or to elect not to have personal data disclosed to a third party or used for any purpose materially different from the purposes stated herein. The purpose of collecting personal information about an investigator physician on this webpage is to allow Medpace to quickly identify and contact physicians for participation in clinical studies. If I wish to exercise any of the rights above, I may contact Medpace at privacy@medpace.com.

I consent

Please check the box below before submitting the form.