Principal Investigator Registration

    Principal Investigator Registration

    PI Name *

    Title

    Study ID# / Sponsor Protocol Number (if any):

    Study Sponsor and/or Lead Site (if Single IRB):

    Name of Practice / Site where Study will be performed *

    Relationship to Site: *
    Faculty
    Employee

    Institution or Organization name *

    Address where study will be performed *

    City *

    State *

    Zip *

    Phone *

    Fax (if applicable):

    Email *

    Contact Person (if not PI)

    Title *

    Address *

    Phone *

    Email *

    Department

    Specialty 1:
    Board Certified *
    YesNo

    Specialty 2:
    Board Certified *
    YesNo

    What type of trials would you like to receive

    (Circle/highlight all that apply):
    Allergy
    Arrhythmias
    Asthma
    Closed Head Injuries
    COPD
    CHF
    Devices
    Diabetes
    Dialysis
    Endocrine
    Fungal
    Rehab Med
    Internal Med
    Geriatrics
    Cardiology
    GI
    Gout
    Hematology
    Hepatitis
    HIV
    Hyperglycemia
    Hypertension
    IBD
    Infectious Disease
    Immunodeficiency Disorders (non-HIV)
    Infertility
    Nephrology
    Obesity
    Osteoporosis
    Pneumonia
    Pulmonary
    RA
    Rheumatology
    Immunodeficiency Disorders (non-HIV)InfertilityCicle Cell
    Skin/Soft Tissue infections
    SLE
    Sleep
    STDs
    Substance Abuse
    Thyroid
    Travel Medicine

    Cancer (list all that apply):

    Adult Neurology (Circle/Highlight all that apply):
    Alzheimer's and Dementia
    Epilepsy
    Migraine
    MS
    Pain
    Parkinson’s Disease
    Stroke

    Anesthesia (Circle/Highlight all that apply):
    General Anesthesia
    Pain Management

    Dentistry (Circle/Highlight all that apply):
    Dental Pain
    General Dental

    Dermatology:
    General Dermatology
    Melanoma
    Acne
    Psoriasis

    Emergency Medicine (Circle/Highlight all that apply):
    Adult ER
    Pediatric ER

    ENT: (Circle/Highlight all that apply):
    General ENT
    Otitis Media
    Sinusitis

    OB GYN: (Circle/Highlight all that apply):
    Female Sexual Dysfunction
    GYN
    Incontinence Infertility
    Menopausal Symptoms
    [checkbox obgyn "Obstetrics""]
    Osteoporosis
    STDs

    Ophthalmology (Circle/Highlight all that apply):
    General Ophthalmology
    Neuro Ophthalmology
    Glaucoma
    Retinal Problems

    How many studies are you currently participating in:

    Support Staff

    YesNo

    YesNo

    Primary Coordinator Contact

    YesNo

    Telephone: *

    E-mail: *

    Additional Information

    Have you ever had an FDA Audit? *YesNo

    If Yes, what year was it done?

    YesNoN/A

    If Yes, Please attach file here

    Did you ever have any medical license issue? (ie: suspensions or probation periods) *YesNo

    Please send an updated version of the PI’s CV (signed and dated within 1 year) and current Medical License.