Home | FAQ | Site Map | Search:  
 
 
. . . . . .
  Quick Links
 
 
Home > Investigative Site Sign-up
 
Investigative Site Sign-up
 
* 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) :


Other :
Are you currently affiliated with any research networks?
If yes, please specify :
Are you a member of ION?
If so, are you an LPP practice?
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?
Years in existence
Does site have an experienced full-time CRC?
If not full-time, what percentage of time is dedicated to research? 
Does site have any additional research staff ?
Please specify :
Does site have a biosafety cabinet for chemotherapy preparation and a chemotherapy infusion area?
Can site utilize Central IRB?
If not, will local IRB grant a waiver? :
Does site have a refrigerator dedicated to drug/and lab specimen storage only?
Dedicated freezer?
Does site have space dedicated to research with access to computer (including email access), fax, copier and commercial delivery service
     
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?
How many patients did site enroll on clinical trials last year? :
How many patients have they enrolled year-to-date? :
     
Trial Participation






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 :
   
Office Address :
Main Address :
City : Zip :
State :
Office Phone :  
Office Fax :  
Email :
Practice Administrator
First Name :
Last Name :
MI :
Office Phone :  
Office Fax :  
Email :
     
     
 
 
 
 
India - IST  IST Time Here   France - CET  CET Time Here  
           
Germany - CET  CET Time Here   USA - EST  EST Time Here  
 
Disclaimer | © Veeda Clinical Research Limited