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Principal Investigator Registration
Principal Investigator Registration
PI Name
*
Title
Name of Practice / Site where Study will be performed
*
Institution or Organization name
*
Address where study will be performed
*
City
*
State
*
Zip
*
Phone
*
Fax
Email
*
Contact Person (if not PI)
Name
*
Title
*
Address
*
Phone
*
Email
*
Department
Select One
Emergency
Medicine
Pediatrics
Psychology
Surgery
Others
Specialities (Select all that apply)
Allergy/Immunology
Anesthesiology
Cardiology
Dental Medicine
Dermatology
Emergency Medicine
Endocrinology
ENT
Gastroenterology
Hematology
Hem/Onc
Infectious Disease
Infertility
Internal Medicine
Nephrology
Nuclear Medicine
OB/GYN
Oncology
Ophthalmology
Orthopedics
Podiatry
Psychiatry
Rheumatology
Sleep
Surgey
Urology
Others
Site Information
How many coordinators do you have?
How many are CCRC Certified?
Does the PI have certification of training in Human Subjects Protection?
*
Yes
No
Does the Coordinator(s) have certification of training in Human Subjects Protection?
*
Yes
No
Please upload the PI’s or Coordinators Human Subjects Protection training certificates
Primary Coordinator Contact
Same as Contact person listed above?
*
Yes
No
Name:
Address:
Telephone:
*
E-mail:
*
Additional Information
Have you ever had an FDA Audit?
*
Yes
No
If Yes, what year was it done?
Was a 483 issued?
*
Yes
No
N/A
If Yes, Please attach file here
Did you ever have any medical license issue? (ie: suspensions or probation periods)
*
Yes
No
If Yes, Please explain:
Please upload a current version of the PI's CV (front page signed and dated within 1 year) and current medical license
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Email
*
First Name
*
Last Name
*
Organization
*
Title
*
What is? 12+48=?
