*Last Name:
*First Name:
*Title:
*Degree:
* Clinic Name & Mailing Address:
* Type of Investigator Practice: (i.e,: Family Practice, Private Practice, etc)
* Investigator Medical Specialty: (i,e,: Pediatrics, Family Medicine etc)
Please indicate the percentage of your patient population below. (i.e,: Male, Female, Outpatient, Impatient, Intensive Care, African Am,Caucasian, Asian, Hispanic, Infant, Child, Adolescent, Adult and other.)
* Research Phase Experience: (i.e,: Phase I, Phase II, Phase II, or Phase IV.)
From which source(s) do you typically enroll most patients? (i.e,: Patient database, Physician Referrals, Advertising, etc
* Has the FDA ever audited your research site? (yes or no) if yes, was a 483 issue?. Please explain. If it doesn't apply in your case please enter "NO Apply"
Please indicate which of the following amenities you have available at your site. (centrifuge, Clinical Laboratory, ECG, Email access, Freezer -20ºC Freezer -70ºC, Internet access, Micro Lab, Pharmacy, Radiology,Respiratory Function Lab, Secure Drug Storage, Secure Records Retention, Sleep Lab and Ultrasound.)
* Your Email: