Investigative Site Sign-up

* Required Fields *Person Submitting Referral :   Enter Referral Date : Practice Demographics *Organization / Institution Name :   Enter Organization / Institution Name *Street Address :  Enter Street Address *City : Enter City *State : Enter State *Zip : Enter Zipcode *Main Phone :                       Enter Main Phone No Main Fax : Practice Type (check all that apply) : Private Practice Single Speciality University Hospital Group Practice Multi-Speciality Clinic Other : Are you currently affiliated with any research networks? Yes No If yes, please specify : Are you a member of ION? Yes No 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? Yes No Years in existence :  Does site have an experienced full-time CRC? Yes No If not full-time, what percentage of time is dedicated to research?  Does site have any additional research staff ? Yes No Please specify : Does site have a biosafety cabinet for chemotherapy preparation and a chemotherapy infusion area? Yes No Can site utilize Central IRB? Yes No If not, will local IRB grant a waiver? Yes No Does site have a refrigerator dedicated to drug/and lab specimen storage only? Yes No Dedicated freezer? Yes No Does site have space dedicated to research with access to computer (including email access), fax, copier and commercial delivery service Yes No             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? Yes No 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 :  Enter First Name MI :  *Last Name :  Enter Last Name *Title :  Select MD DO Ph.D  Please Select Title *Office Phone :     Enter Phone No Office Fax :    *Email :  Please Enter Email Address Please Enter Valid Email Address Clinical Research Contact (Primary Clinical Research Coordinator [CRC]) *First Name :  Enter First Name MI :  *Last Name :  Enter Last Name *Title :  Select Director Of Research Research Manager Research Co-ordinator  Please Select Title    Same as Practice *Office Address :  Enter Office Address *City :    Enter City   *State :    Enter State *Zip :    Enter Zipcode *Office Phone :     Enter Phone No Office Fax :    *Email :  Please Enter Valid Email Address Please Enter Email Address Practice Administrator *First Name : Enter First Name MI :  *Last Name :  Enter Last Name    Same as Practice *Office Address :  Enter Office Address *City :    Enter City   *State :    Enter State *Zip :    Enter Zipcode *Office Phone :     Enter Phone No Office Fax :    *Email :  Please Enter Valid Email Address Please Enter Email Address