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 *
Name *
Title *
Address *
Department Select OneEmergencyMedicinePediatricsPsychologySurgeryOthers
Specialty 1: Board Certified * YesNo
Specialty 2: Board Certified * YesNo
(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:
How many coordinators do you have?
How many are CCRC Certified?
Does the PI have certification of training in Human Subjects Protection? *YesNo
Does the Coordinator(s) have certification of training in Human Subjects Protection? *YesNo
Please upload the PI’s or Coordinators Human Subjects Protection training certificates
Same as Contact person listed above? *YesNo
Name:
Address:
Telephone: *
E-mail: *
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 send an updated version of the PI’s CV (signed and dated within 1 year) and current Medical License.
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First Name *
Last Name *
Organization *
What is? 12+48=?
