Biomedical Research Alliance of New York, LLC

Investigator Database Information Form Non-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. However there is a one time, non-refundable handling fee of $50.00 for site registration for all new sites wishing to join the BRANY alliance. Payment of the fee does not guarantee acceptance. Please see PayPal link on this form. BRANY accepts MasterCard, Visa, Discover credit accounts. For investigators who are affiliated with or employed by a BRANY alliance member site, the fee will be waived. Please complete the short form provided at this link click here

Please include an electronic version of your current CV.

Fields in blue are optional

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 Veterans Administration 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

50%
60%
70%
80%
90%
Over 90%
Support Staff
Primary Coordinator Contact
MD Coordinator Other
Training
Yes No
Yes No
Facilities
Yes No
PI RN Non-RN
Equipment
Yes No
Institutional Review Board
Yes No
Yes No
Yes No
Yes No
If Yes, please fax the 483 form to 516-470-6903 or e-mail to rmaturo@brany.com
Local Research Context
Neutral Positive Negative
Explain:
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)