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: * Employee
Other:
Address where study will be performed *
City *
State *
Zip *
Phone *
Email *
Name *
Title *
Address *
Department Select OneEmergencyMedicinePediatricsPsychologySurgeryOthers
Specialty 1: Board Certified YesNo
Specialty 2: Board Certified YesNo
How many studies are you currently participating in?:
How many coordinators do you have?
How many are CCRC Certified?
Does the PI have certification of training in Human Subjects Protection? *YesNo
Have you ever had an FDA Audit? *YesNo
If Yes, what year was it done?
Was a 483 issued? *YesNoN/A
If Yes, Please attach file here
Did you ever have any medical license issue? (ie: suspensions or probation periods) *YesNo
If Yes, Please explain:
Please upload an updated version of the PI’s CV, HSP training, and current Medical License.
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First Name *
Last Name *
Organization *
What is? 12+48=?
