Investigator Database Information Form U.S. Sites

There is never an ongoing fee for a site to be part of the BRANY alliance or to be presented with opportunities. Please complete and submit the registration form below and we will contact you. For investigators already affiliated with or employed by an existing BRANY alliance member site, please complete the short form provided by the link at the bottom of this page.

Please include an electronic version of your current CV.

Fields in blue are optional

Academic Institution SMO Private Practice
Principle Investigator
Yes No
If multiple PIs, click here to fill out short info form for each.
Specialty
Yes No
Yes No
Trials

What type of trials would you like to receive?

ATTENTION
(Multiple types maybe selected by using the Control key when making a selection) Adult Medicine

Adult Neurology

Anesthesia

Dentistry

Dermatology

Emergency Medcine

ENT



OB GYN

Ophthalmology

Pediatrics

Podiatry

Psychiatry

Radiology

Surgery

Urology
List additional areas of expertise if not included above.
Practice Setting What is your Practice Setting: (Check all that Apply)
University Based Research Center Solo/Group Practice Hospital Staff Medical School Faculty Urgent Care Center Consortium/Network Rehab Hospital /Clinic Nursing Home/Extended Care Free standing research center
Please provide the following information regarding your practice settings:
City Suburb
Demographics
Yes No
Research Experience










































Support Staff
Primary Coordinator Contact
MD Coordinator Other
Training
Yes No
Acceptable certificates include academic medical center earned CME, Dunn and Chadwick's Protecting Study Volunteers in Research or http://cme.cancer.gov/c01
Yes No
Certificates are required for IRB approvals.
Facilities
Yes No
PI RN Non-RN
Equipment
Yes No
Yes No
Institutional Review Board
Yes No
Yes No
Yes No
Yes No
If Yes, please fax the 483 form to 516-470-6903
Local Research Context
Neutral Positive Negative
Explain:
Please recommend a possible local consultant (someone not at your site) to our independent IRB to answer questions regarding local attitudes.
References
We will be contacting Sponsors and CRAs you have worked within the past to assess GCP compliance.
Please list two references
Attachments
(ie: CVS 483 Reports)

For investigators who are affiliated with or employed by a BRANY alliance member site, please complete the short form provided at this link click here.