Investigator Form Test - ConfidenceResearch

BECOME A CLINICAL INVESTIGATOR

For Sites

* By completing this form you agree that Confidence and Confidence’s representatives may contact you and/or your staff to discuss ongoing clinical trial opportunities. Confidence will not sell your contact information to any third party, but may provide it to (1) Clinical Trial Sponsors for further consideration your participation in clinical trials; (2) Confidence’s agents, contractors and business partners for the purpose of clinical trial conduct; (3) Confidence’s affiliates and subsidiaries; (4) Law enforcement agencies, regulatory agencies as necessary to comply with legal or regulatory obligations

BECOME A CLINICAL INVESTIGATOR

For Sites

Please complete information in the form below to the best of your ability. If you cannot or don’t want to answer any of the questions, please leave them blank.

Principal Investigator Name and Contact Information:

Name

Phone

Please provide the following information about the Principal Investigator:

Number of years in Clinical Research:

Number of years

Therapeutic area:

Select

Number of industry-sponsored clinical trials conducted in the last 5 years:

Number clinical trials

Add Investigator Checkbox

Add Investigator

Investigator 2 Name and Contact Information:

Name

Phone

Please provide the following information about Investigator 2:

Number of years in Clinical Research:

Number of years

Therapeutic area:

Select

Number of industry-sponsored clinical trials conducted in the last 5 years:

Number clinical trials

Add Investigator Checkbox

Add Investigator

Investigator 3 Name and Contact Information:

Name

Phone

Please provide the following information about Investigator 3:

Number of years in Clinical Research:

Number of years

Therapeutic area:

Select

Number of industry-sponsored clinical trials conducted in the last 5 years:

Number clinical trials

Add Investigator Checkbox

Add Investigator

Investigator 4 Name and Contact Information:

Name

Phone

Please provide the following information about Investigator 4:

Number of years in Clinical Research:

Number of years

Therapeutic area:

Select

Number of industry-sponsored clinical trials conducted in the last 5 years:

Number clinical trials

Add Investigator Checkbox

Add Investigator

Investigator 5 Name and Contact Information:

Name

Phone

Please provide the following information about Investigator 5:

Number of years in Clinical Research:

Number of years

Therapeutic area:

Select

Number of industry-sponsored clinical trials conducted in the last 5 years:

Number clinical trials

Add Investigator Checkbox

Add Investigator

Investigator 6 Name and Contact Information:

Name

Phone

Please provide the following information about Investigator 6:

Number of years in Clinical Research:

Number of years

Therapeutic area:

Select

Number of industry-sponsored clinical trials conducted in the last 5 years:

Number clinical trials

Add Investigator Checkbox

Add Investigator

Investigator 7 Name and Contact Information:

Name

Phone

Please provide the following information about Investigator 7:

Number of years in Clinical Research:

Number of years

Therapeutic area:

Select

Number of industry-sponsored clinical trials conducted in the last 5 years:

Number clinical trials

Add Investigator Checkbox

Add Investigator

Investigator 8 Name and Contact Information:

Name

Phone

Please provide the following information about Investigator 8:

Number of years in Clinical Research:

Number of years

Therapeutic area:

Select

Number of industry-sponsored clinical trials conducted in the last 5 years:

Number clinical trials

Add Investigator Checkbox

Add Investigator

Investigator 9 Name and Contact Information:

Name

Phone

Please provide the following information about Investigator 9:

Number of years in Clinical Research:

Number of years

Therapeutic area:

Select

Number of industry-sponsored clinical trials conducted in the last 5 years:

Number clinical trials

Add Investigator Checkbox

Add Investigator

Investigator 10 Name and Contact Information:

Name

Phone

Please provide the following information about Investigator 10:

Number of years in Clinical Research:

Number of years

Therapeutic area:

Select

Number of industry-sponsored clinical trials conducted in the last 5 years:

Number clinical trials

Site Name and Address:

Organization

Department

Street Address

City

State

Zip

Please provide Contact Person information for future contact:

Name

Position

Phone

Site Information

Please provide the type of your site:

Please specify the type of your site

Please provide the following information about Study Coordinators at your site:

Total number of Coordinators at your site:

Number of Coordinators

Number of Coordinators with 3+ years of experience in clinical research:

Number of Coordinators with 3+ years

What patient age groups do you treat? (Mark all that apply)

What type of IRB / EC does your Site use?

Only Central Only Local Either Both approvals are needed

Please enter the name of the preferred Central IRB / EC (if applicable):

Preferred Central IRB / EC

How many weeks are typically required to receive IRB / EC approval?

Number Of Weeks

Are there any other committees/approvals needed for your site?

Yes No

If YES, please explain:

Explanation

What is the typical time for your site to execute a Clinical Trial Agreement (CTA)? (weeks)

Number Of Weeks

Are there any other committees/approvals needed for your site?

Yes No Not applicable (please comment)

Comment

I confirm that I am the Principal Investigator of this Site listed on Question 1 of this Questionnaire

I confirm that I completed the questionnaire on behalf of the Principal Investigator.

REQUEST PROPOSAL

For Sites

BECOME A CLINICAL INVESTIGATOR

For Sites

Principal Investigator Name and Contact Information:

Please provide the following information about the Principal Investigator:

Investigator 2 Name and Contact Information:

Please provide the following information about Investigator 2:

Investigator 3 Name and Contact Information:

Please provide the following information about Investigator 3:

Investigator 4 Name and Contact Information:

Please provide the following information about Investigator 4:

Investigator 5 Name and Contact Information:

Please provide the following information about Investigator 5:

Investigator 6 Name and Contact Information:

Please provide the following information about Investigator 6:

Investigator 7 Name and Contact Information:

Please provide the following information about Investigator 7:

Investigator 8 Name and Contact Information:

Please provide the following information about Investigator 8:

Investigator 9 Name and Contact Information:

Please provide the following information about Investigator 9:

Investigator 10 Name and Contact Information:

Please provide the following information about Investigator 10:

Site Name and Address:

Please provide Contact Person information for future contact:

Site Information

Please provide the type of your site:

Please provide the following information about Study Coordinators at your site:

What patient age groups do you treat? (Mark all that apply)

What type of IRB / EC does your Site use?

How many weeks are typically required to receive IRB / EC approval?

Are there any other committees/approvals needed for your site?

What is the typical time for your site to execute a Clinical Trial Agreement (CTA)? (weeks)

Are there any other committees/approvals needed for your site?

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