PI Name *
Name of Practice / Site where Study will be performed *
Relationship to Site: *
Institution or Organization name *
Address where study will be performed *
Fax (if applicable):
Board Certified *
Board Certified *
(Circle/highlight all that apply):
AllergyArrhythmiasAsthmaClosed Head InjuriesCOPDCHFDevicesDiabetesDialysisEndocrineFungalRehab MedInternal MedGeriatricsCardiologyGIGoutHematologyHepatitisHIVHyperglycemiaHypertensionIBDInfectious DiseaseImmunodeficiency Disorders (non-HIV)InfertilityNephrologyObesityOsteoporosisPneumoniaPulmonaryRARheumatologyCicle CellSkin/Soft Tissue infectionsSLESleepSTDsSubstance AbuseThyroidTravel Medicine
Cancer (list all that apply):
Adult Neurology (Circle/Highlight all that apply):
Alzheimer's and DementiaEpilepsyMigraineMSPainParkinson’s DiseaseStroke
Anesthesia (Circle/Highlight all that apply):
General AnesthesiaPain Management
Dentistry (Circle/Highlight all that apply):
Dental PainGeneral Dental
Emergency Medicine (Circle/Highlight all that apply):
Adult ERPediatric ER
ENT: (Circle/Highlight all that apply):
General ENTOtitis MediaSinusitis
OB GYN: (Circle/Highlight all that apply):
Female Sexual DysfunctionGYNIncontinence InfertilityMenopausal SymptomsObstetricsOsteoporosisSTDs
Ophthalmology (Circle/Highlight all that apply):
General OphthalmologyNeuro OphthalmologyGlaucomaRetinal 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
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 *
What is? 12+48=?