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| Previous Clinical Research Experience (if not applicable, please leave blank): |
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| Pharmaceutical Drug/Compound |
Vaccine |
| Gene-based Therapies |
Cell therapy |
| Radiology/contrast media |
Medical Device |
| Pharmacokinetics |
Diagnostics |
| Genetics |
Nutriceuticals |
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| Current Research/Practice Setting (if not applicable, please leave blank): |
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Phase I Unit |
Hospital Outpatient Care |
Nursing Home |
General Practice |
| Private Hospital (bed capacity)
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Public Hospital (bed capacity)
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| Research Center |
University Hospital (bed capacity)
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VA/Military Hospital/Clinic(bed capacity)
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SMO - please state name and website address:
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| What age group do you treat? (if not applicable, please leave blank) |
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Neonatology |
Paediatric |
Adolescent |
Adult |
Geriatric |
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| Ethics Committee/Institutional Review Board: |
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| Please indicate whether you work with an IEC/IRB? (if not applicable, please leave blank) |
Central |
Local |
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| Research Phase Experience (if not applicable, please leave blank): |
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Phase I |
Phase II |
Phase III |
Phase IV |
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| Site Capabilities (if not applicable, please leave blank): |
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-70° Freezer |
-20° Freezer |
Centrifuge |
On-site Lab |
On-site Pharmacy |
Home Health |
Ultrasound |
X-Ray |
ECG |
DEXA Scanner |
CT Scanner |
Radioisotopes |
Magnetic Resonance Imaging equipment |
Sleep lab |
Emergency department |
Intensive Care Unit |
Maternity |
Rehabilitation for cardiac patients |
Cardiac catheterisation |
Heart transplantation surgery |
Respiratory physiology equipment |
Radiotherapy department |
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| Do you have a computerised patient database (electronic health record system)? (if not applicable, please leave blank) |
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| YesNo |
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| Therapeutic Area (if not applicable, please leave blank): |
| Please indicate your primary area of specialty/sub-specialty |
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| Do you have experience in conducting studies using Electronic Data Capture (EDC)? (if not applicable, please leave blank) |
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| YesNo |
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| Would you be interested in participating in studies using EDC? (if not applicable, please leave blank) |
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| YesNo |
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| *Please enter your query or comments below: |
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