Clinical Investigator Questionnaire

We would appreciate your assistance in providing the following information, which will be included in our database to help us attract studies of interest and inform investigators of upcoming studies. Please fill out this form and click the "Submit" button at the bottom when finished. Thank you.

Faculty Investigator

Name (required) Phone (required)
Beeper No. FAX No.
E-mail Address
Year Started Clinical Research/Trials

Primary Study Coordinator

Name Phone
Beeper No. FAX No.
E-mail Address Campus Box

What are your areas of interest for clinical trials?

1. Select Therapeutic Areas/Uses: Select your primary Therapeutic Area, and secondary Area(s) if applicable. Press Ctrl key (Macintosh: Command key) while clicking to make multiple selections. To deselect an item, hold down the Ctrl/Command key and click once.

Therapeutic Areas Therapeutic Uses

Other Areas/Uses:

Phase:

2. List specific Patient Populations/Medical Conditions here (e.g. Diabetes, CAB Surgery, Pediatric patients):


Please list any other service or area of expertise that you may want to offer as a resource to industry sponsors:
(A CCS staff member will contact you to discuss details)


What assistance or services are you most likely to need from the CCS?

Submitting studies for IRB approval from the Human Studies Committee
Preparing/negotiating study budget
Clinical Research Coordinator services such as: Assistance with planning (coordinating pre-study site visit, attending investigator’s meeting, arranging research accounts, etc.), study initiation, subject enrollment, patient scheduling, administration of study drug, patient assessment, completion of case report forms, coordinating study monitor visits.
Database development services (patient registries, electronic case report forms, etc.)
Subject recruitment services
Use of outpatient clinical facilities

Additional comments and/or questions:

 

 

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