Please provide the information requested below to be entered into our investigator database. In addition, we encourage you to send any brochures or other information you would like us to have on file to the attention of Investigator Database Coordinator in our Bristol office.

* indicates required fields


Investigator Information
Investigator Name*:


(first name)*
(m.i.)
(last name)*
 (suffix)
Degree*:


Employment Status:

Current Medical Licenses (please select all that apply)



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Site Information
Site Name:*
Site Address:*
City:*
State/Province:* /
Country:*
Zip/Postal Code:*
Phone:* Ext.
Fax:
E-mail:
Web site:

Primary Contact:*




(first name)*
(m.i.)
(last name)*
 (suffix)
Street Address:
City:
State/Province: /
Country
Zip/Postal Code:
Phone:* Ext
E-mail:
Practice/Network Type (please check all that apply)*
Investigator Qualifications
*Is this physician board certified?

* If yes, please select all areas of certification that apply:


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If there are other areas, please list here:

* Areas of Subspecialization (please select all that apply):


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Have you obtained clinical investigator certification?

If yes, clinical certification (please select all that apply):


(Hold down the "CTRL" key to select multiple areas)

If other certification, please list here:

*Therapeutic areas in which this physician has clinical trial experience (please select all that apply):


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*Disease categories in which this physician has clinical trial experience (please select all that apply):


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Others:

* Estimate the number of clinical studies this physician has performed in the past 5 years.

* How much time is dedicated to performing clinical research?

* Has the physician listed ever worked with CTMS?

*If yes, in what capacity?

* Please list protocol(s):

* Research phase experience of the registering physician (please select all that apply):

Site Qualifications
*Does this site employ full-time study coordinator(s) dedicated to research?

Does this site use sub-investigators in clinical research? 

*From which source(s) does the site typically enroll study patients? (please select all that apply)

*This site has access to the following patient population, by age (please select all that apply):

*What type of IRB does the site use?

*If local, specify how often your IRB meets:

If local, average response time to review documents:

Does the site have experience with Electronic Data Capture?
 

Available Resources (please check all that apply):

Comments:

IMPORTANT NOTICE: CTMS is collecting the information in this Investigator Registration Form for CTMS' business purposes. CTMS may use information you provide to identify potential investigators for particular clinical trials, including providing this information to trial sponsors. The data may be used to monitor and assess clinical trials and the monitoring and reporting of adverse events. This information may be used to communicate with you, including providing you with updates and alerts regarding clinical trials and CTMS activities. The information may be used to verify the accuracy of any information previously provided to us. The information that you provide may be used in individual studies. The information may also be provided as appropriate to the FDA or other regulatory bodies. By submitting the information about you to us, you agree to the collection, use, and disclosure of the information by CTMS for these purposes.