Investigator Registration

1. Principal Investigator Details
First Name:
Middle Name:
Last Name:

2. Contact Details
Institution Name:
Type of Institution: (Select Only One)
Private Practice Public/Government
VA/Military Hospital University Academic or University Research Center
Other (specify)  
Mailing Address: Same as above
Zip Code/Postal Code:
Region: (Select Only One)
North America Western Europe Central and Eastern Europe Latin America Asia and Pacific
Institution Website:
Institution Phone:
Institution Fax:

Central and/or Local IRB/Ethics Board
3. Can your site use any central IRB/Ethics Board? Yes No NA
a. If no, please tell us the names of the Central IRB/Ethics Board you are able to work with?  
4. How often do your Central and/or Local IRB/Ethics Board meet?
5. Are there any other committees in addition to the Central and/or Local IRB/Ethics Board involved in the protocol review process? Yes No NA
The following questions apply to sites with Local IRBs/Ethics Board only
6. How long before Local IRB/Ethics Board meetings must you submit protocol documents (i.e. 2 weeks, 4 weeks)?
7. What is the average time from the Local IRB/Ethics Board meeting to having approval documentation in hand?

Research Experience
8. How many years of sponsor driven clinical trial experience do you have?
9. What Therapeutic Areas and Indications do you have patient access to? Please include # of Years.
10. What is your Phase Experience (I, II, III & IV)? How many trials have you conducted in each Phase?

11. What Type of radiographic tests available: (Check all that apply)
Conventional CT Scan Spiral CT Scan CT angiography Fluoroscopy with scanning MRI
MRA PET Scan Mammography X-Ray Bone Scan
Thyroid Scan Thallium cardiac stress test Ultrasound
12. Can digitized scans recorded on optical disc or tape be provided? Yes No
13. Does the institution have the equipment onsite or is it being contracted out? Onsite Contracted Out

14. Does the site have a Local pharmacy to store/dispense trial drug? Yes No
If yes, is the pharmacy on-site? Yes No
15. Does the site Process labs locally? Yes No
16. Is there a Pathology lab onsite? Yes No
17. Does the site Pre-screen for genetic mutations? Yes No
18. Does the site have In-patient capability? Yes No
19. Does the site have direct access to the electronic source documents Yes No
20. What Supplies/Equipment are available on site: (Check all that apply)
ECG -20C freezer -70C freezer Centrifuge CAT scan
Resuscitation equipment/facilities Access to dry ice
21. What type of dedicated staff do you have to assist in research? (Check all that apply)
Sub-Investigator Pharmacist Study Nurse
22. Does your site have any Satellite Sites? Yes No
If yes, how many satellite sites do you have?