Investigative Site Sign-up

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* Required Fields
Person Submitting Referral	:		Date	:
Practice Demographics
Organization / Institution Name	:
Street Address	:
City	:		Zip	:
State	:
Main Phone	:		Main Fax	:
Practice Type (check all that apply) :
Private PracticeSingle SpecialityUniversityHospital Group PracticeMulti-SpecialityClinic
Other :
Are you currently affiliated with any research networks?					YesNo
If yes, please specify :
Are you a member of ION?			YesNo
If so, are you an LPP practice?			YesNo
Number of Oncology Physicians participating in research :
Number of “New” patients seen each year :
Number of locations to be opened to Veeda Oncology :
If more than one location will be open how is oversight provided for these satellite(s) :


Research Demographics
Does site have an established clinical research program?					YesNo
Years in existence		YesNo
Does site have an experienced full-time CRC?			YesNo
If not full-time, what percentage of time is dedicated to research?
Does site have any additional research staff ?			YesNo
Please specify :
Does site have a biosafety cabinet for chemotherapy preparation and a chemotherapy infusion area?					YesNo
Can site utilize Central IRB?			YesNo
If not, will local IRB grant a waiver? :
Does site have a refrigerator dedicated to drug/and lab specimen storage only?					YesNo
Dedicated freezer?		YesNo
Does site have space dedicated to research with access to computer (including email access), fax, copier and commercial delivery service					YesNo

Clinical Research Experience
CRC Research Experience years :
Lead Principal Investigator Research Experience years :
Have any of the site’s physicians been the lead PI on an Investigator Initiated Trials?					YesNo
How many patients did site enroll on clinical trials last year? :
How many patients have they enrolled year-to-date? :

Trial Participation
Pharmaceutical / Sponsor-Generated Trials Treatment Supportive Care Cooperative / Group Trials Data Collection / Retrospective Trials Investigator-Initiated Trials Compassionate Use Trials
Other:

Contacts
Principal Physician Contact for Clinical Research
First Name	:
Last Name	:
MI	:
Office Phone	:
Office Fax	:
*Email	:
Clinical Research Contact (Primary Clinical Research Coordinator [CRC])
Title	:
First Name	:
Last Name	:
MI	:
		Same as Practice
Office Address	:
Main Address	:
City	:		Zip	:
State	:
Office Phone	:
Office Fax	:
Email	:
Practice Administrator
First Name	:
Last Name	:
MI	:
Office Phone	:
Office Fax	:
Email	:

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