Investigator Enrollment Form

Investigator Name
Investigator Address

City		State		Zip

Phone		Fax

Email

Specialty

Board Certified

	Yes		No

Subspecialty

Board Certified

	Yes		No

Type of Practice

	Solo		VA		Group Single Specialty
	Group		Research Only		Hospital
	Multi-Specialty		University		Other

What are your particular therapeutic areas of expertise? Please provide the following: Area of expertise: (i.e.: Stroke, AIDS) Do you have clinical research experience in this area?

1.	Yes	No	# of previous studies
2.	Yes	No	# of previous studies
3.	Yes	No	# of previous studies

Preferred Phases:

I	II	III	IV

IRB	Central	Local

Trials	Inpatient	Outpatient

Best Days/Times to Reach Invetigator:

Day(s) of Week		Time(s)

Research Coordinator Name		Phone

# previous trials

If you do not have an experienced research coordinator available, would you be willing to contract with us to provide one?

	Yes		No

Who would we contract with?

Investigator	Practice	Institution	Other

Have you ever been audited by the FDA?

	Yes		No

If yes, please provide copy of any report received (for internal use only).

Pharmacy on Site?	Yes	No
Clinical Lab on Site?	Yes	No
Phlebotomy on Site?	Yes	No
Freezer	-20 to -70	-70 or below
Centrifuge Available?	Yes	No
Secure Drug Storage?	Yes	No
On Site Radiology?	Yes	No
Space for Monitor?	Yes	No

Are you a member of any other public or private research organizations?

	Yes		No