Investigator Database Investigator Profile: Fields marked with an * are required: Institution: * Address: * City: * State/Country: * Postal Code: * Phone Number: * Fax: * Website: Submitter Email Address: * Principal Investigator: * PI Title: * PI Phone Number: * PI Fax Number: * PI Email Address: * Coordinator Name: Coordinator Phone Number: Coordinator Fax Number: Coordinator Email Address: Practice Setting: Setting: Please choose one of the following: Group Managed Health Care Mental Health Multi-Specialty Nursing Home Private Practice Student Health Center TMO/SMO Urgent Care Center VA/Military Private Hospital Rehab. Hospital/Clinic University Hospital Other (Specify) If other please specify: Research Specialties: (Check all that apply) AIDS/HIV Allergy Biologics Cardiovascular Dental Dermatology Devices Diagnostics Endocrinology Gastroenterology Hematology Hepatic Immunology/Infectious Diseases Metabolism Musculoskeletal Nephrology/Urology Neurology Nutrition OB/GYN Oncology Ophthalmology Osteopathy Otorhinolaryngology Pediatrics/Neonatology Pharmacology/Toxicology Psychiatry/Psychology Pulmonary/Respiratory Radiology Rheumatology Sexual Dysfunction Surgery Transplantation Trauma/Emergency Medicine Past Experience: (Check all that apply) Pharmaceutical Biologic Nutritional Supplement Device Diagnostic Phase I Phase II Phase III Phase IV Research Specialties: (Please list any specialties and indicate board certified or eligible for each physician.) Type of IRB: Local Central Have You Been Audited by Regulatory Authority:No Yes If yes, date done and by when : Have You Been Audited by Sponsor: No Yes If yes, date done and by when: Profile Last Updated:
Fields marked with an * are required:
Institution: * Address: * City: * State/Country: * Postal Code: * Phone Number: * Fax: * Website:
Submitter Email Address: * Principal Investigator: * PI Title: * PI Phone Number: * PI Fax Number: * PI Email Address: * Coordinator Name: Coordinator Phone Number: Coordinator Fax Number: Coordinator Email Address:
Setting: Please choose one of the following: Group Managed Health Care Mental Health Multi-Specialty Nursing Home Private Practice Student Health Center TMO/SMO Urgent Care Center VA/Military Private Hospital Rehab. Hospital/Clinic University Hospital Other (Specify)
If other please specify:
Research Specialties: (Check all that apply)
AIDS/HIV Allergy Biologics Cardiovascular Dental Dermatology Devices Diagnostics Endocrinology Gastroenterology Hematology
Hepatic Immunology/Infectious Diseases Metabolism Musculoskeletal Nephrology/Urology Neurology Nutrition OB/GYN Oncology Ophthalmology Osteopathy
Otorhinolaryngology Pediatrics/Neonatology Pharmacology/Toxicology Psychiatry/Psychology Pulmonary/Respiratory Radiology Rheumatology Sexual Dysfunction Surgery Transplantation Trauma/Emergency Medicine
Past Experience: (Check all that apply)
Pharmaceutical Biologic Nutritional Supplement Device Diagnostic
Phase I Phase II Phase III Phase IV
Research Specialties: (Please list any specialties and indicate board certified or eligible for each physician.) Type of IRB: Local Central
Have You Been Audited by Regulatory Authority:No Yes
If yes, date done and by when : Have You Been Audited by Sponsor: No Yes If yes, date done and by when: Profile Last Updated:
Have You Been Audited by Sponsor: No Yes
If yes, date done and by when:
Profile Last Updated:
