Principal Investigator Registration

Principal Investigator Registration

PI Name *

Title

Name of Practice / Site where Study will be performed *

Relationship to Site: *
Faculty
Employee

Institution or Organization name *

Address where study will be performed *

Contact Person (if not PI)

Name *

Title *

Address *

DepartmentSelect OneEmergencyMedicinePediatricsPsychologySurgeryOthers

Specialty 1:
Board Certified *
Yes No

Specialty 2:
Board Certified *
Yes No

What type of trials would you like to receive

(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

Dermatology:
General DermatologyMelanomaAcnePsoriasis

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:

Support Staff

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

Primary Coordinator Contact

Same as Contact person listed above? *YesNo

Name:

Address:

Telephone: *

E-mail: *

Additional Information

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.