Investigator Registration Form

Site/Office/Practice

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Site Web Address

Contact person

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Site Information

Description (check one)

Hospital Private Practice Clinic Clinical Research Site University Other

If other specify

Years of clinical research experience

IRB (check one)

Local Central Both/either

Phase Experience (check all that apply)

Phase I Phase II Phase III Phase IV Device

Therapeutic Expertise (check all that apply)

Analgesia/Anesthesia Cardiovascular CNS/Psychiatric Dermatology Device Endocrinology Gastroenterology Genitourinary Hematology HIV/AIDS Immunology Infectious Disease Oncology Ophthalmology Pediatrics Pulmonary/Respiratory Rheumatology/Musculoskeletal Transplant Urology Vaccine Other