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Clinical Research Services
Investigator Enrollment and Database form

Please complete and submit this form so we can finalize your adjunct appointment with Exodon. We appreciate your time and look forward to building your organization's clinical trial services.

This information is strictly confidential and is not used for any purpose other than our internal investigator credentialing process and to perform a site feasibility analysis prior to delivering a study to you and your organization.

Investigator/Researcher Information

Please fill the form below. All the fields marked with a '*' are mandatory:

User Information
   
* Investigator Name:
* Title and Degree(s):
* Address 1:
Address 2:
* City:
* State/Province:
* Zip/Postal Code:
* Country:
* Phone and Ext:
Fax:
* E-mail:
* Clinical Speciality:
* Is investigator is a part of Consortium Leader:
Yes No Consortium Name:
* Is investigator is a part of Site:
Yes No Site Name:
* Board Certified
(Clinical Speciality) :
Yes No
Subspeciality:
BoardCertified:
(Subspeciality)
Yes No
Best Days of Week to Reach
Investigator:
Best Times to Reach Investigator:
     
     
Clinical Research Specialty: (e.g., Stroke, Dementia, Pain, etc.)
   
1. Avg. # of previous studies  
2. Avg. # of previous studies  
3. Avg. # of previous studies  
4. Avg. # of previous studies  
5. Avg. # of previous studies  
6. Avg. # of previous studies  
   
* For how many of these studies were you the Principal Investigator?
Which type of clinical trials do you prefer?
Phases:
None I II III IV
List the clinical research rating scales, tests, inventories, etc. that you consider yourself to be well trained and
experienced to administer (e.g., the Brief Psychiatric Rating Scale, the Unified Parkinson's Disease Rating Scale
, etc.)
To be completed by Investigator only
These questions need to be answered by the researcher/clinician only. Please circle your response.
  1. After reviewing a study protocol, how much time do you think you will need to decide if you want
to participate in a study
1 hour or less
2-24 hours
More than 1 day
2-3 days
Greater than 4 days
 
  2. What is your tolerance level for making decisions that might have large negative consequences?
Very tolerant
Moderately tolerant
Not very tolerant
 
  3. Do you prefer to be a Principal Investigator on studies?
As often as possible
At least half of the time
Doesn't matter
 
  4. How important is it for your site to be able to compete against other clinical research sites?
Very Important
Moderately Important
Not very Important
 
  5. How important is it to move beyond the status quo and develop a cutting edge clinical research practice?
Very Important
Moderately Important
Not very Important
 
  6. When making decisions, how important is getting the project completed versus being sure you are correct?
Very Important
Moderately Important
Not very Important
 
  7. How would you rate your level of persistence?
Very Persistent
Moderately Persistent
Not Very Persistent
 
  8. When making important decisions, how worried do you typically get?
Very Worried
Moderately Worried
Not Very Worried
 
  9. How absorbed do you become in a single clinical research study?
Very Absorbed
Moderately Absorbed
Not Very Absorbed
 
  10. When working on a research hypothesis how much do you value lively and spirited interaction from others?
Very Much
Moderately
Not Very Much
 
  11. When working on a research hypothesis how much do you value facts over theory?
Very Much
Moderately
Not Very Much
 
  12. How important is saving money when conducting research?
Very Important
Moderately Important
Not Very Important
 
 
Site/Practice Information
  Primary contact at your practice/site:    
  Name:
 
  Email:
 
 Phone number and extension:
 
   
  Please indicate what type of medical record system you use in your practice:
Paper Word ECAST EMR Other EMR
   
Medical Records Coordinator Name:
 
Medical Records Coordinator Email:
 
Medical Records Coordinator Phone
Number and extension:
 
   
  Do you have a clinical research
coordinator on site?
Yes No
 
Research Coordinator Name:
 
Research Coordinator Email:
 
Research Coordinator Phone Number
and extension:
 
Number of Previous Trials:
 
   
 
If you do not have an experienced research coordinator available,
Exodon will provide one.
For more information check here:
 
 
 
  Type of Practice:
Solo Group Multi-Speciality VA Research Only University Hospital
   
If necessary would you be able to admit or arrange for admission of a clinical trial patient at hospital that
would allow thatpatient to continue participating in the clinical trial.
Yes No
If yes, please enter the name(s) of the hospital:
 
  Average number of monthly patients
you treat from all clinical research sites
listed above :
 
   
   
Please assign a percentage to this monthly average of patients from the following categories:
Affective Disorders:
%
  
Autoimmune Disorder:
%
 
Brain Tumors:
%
 
Cardiovascular Disorders:
%
 
CerebrovascularDisorders:
%
 
CNS Infectious Disorders:
%
  
Cognitive Impairmentand Dementia:
%
 
Eating Disorders:
%
 
Endocrinology Related Conditions:
%
  
Gastroenterology Related Disorders:
%
  
Headaches Pain:
%
  
Hematological Conditions:
%
  

Immunological and non-CNS Infectious
Related Disorders:
%
  
Movement Disorders:
%
  
Multiple Sclerosis:
%
  
Musculoskeletal Related Disorders:
%
  
Nephrology and Urological Disorders:
%
  
Neurodevelopmental Disorders:
%
  
Neurodiagnostics/Neurophysiology Studies:
%
  
Neuroendocrine:
%
  
Neurogenomics/Neurogenetics
%
  
Neuromuscular Disorders:
%
  
Neuropsychiatric Disorders:
%
  
Obstetrics and Gynecology Related Disorders
%
  
Oncology non-CNS Related Disorders:
%
  
Ophthalmologic Diseases:
%
  
Otolaryngology:
%
 
Personality Disorder:
%
  
Pulmonary and Respiratory Diseases:
%
  
Rheumatology Related Disorders
%
  
Seizures/Epilepsy
%
  
Sleep Disorders:
%
  
Substance Abuse/Addiction
%
  
Traumatic Brain and Spinal Cord Injury
%
  
 
 
Please estimate race, age and gender percentages of patients/subjects:
Race    
Caucasian:
%
  
AfricanAmerican:
%
  
Asian:
%
  
Hispanic:
%
  
Other:
%
  
   
Age    
0-11:
%
 
12-18:
%
 
19-39:
%
  
40-59:
%
  
Above 60:
%
  
   
Gender    
Male:
%
 
Female:
%
 
   
What percentage of your patients are
outpatients:
%
 
  Indicate the percentage of patients that will
need to go through an internal or institutional
IRB in addition to the study's IRB
%
  
  If your site requires and internal IRB, on
average how many days lapse from the
date of IRB submission to the IRB response
days
 
   
Please enter the name of IRB(s) used by you
or your group
 
  On average, how long does it take you or your
group to accept and sign a clinical researchcontract
from the time you receive the initial protocol
 
  Have you or your group received an FDA 483.
If yes, describe outcome
 
   
 
Facility information
  Please indicate the name of each of your sites (Fill atleast one):
1:
 
2:
 
3:
 
4:
 
5:
 
   
Please indicate if you have daily access to:
Pharmacy:
Yes No
 
For site # (s):
 
Clinical Lab:
Yes No
 
For site # (s):
 
Phlebotomy:
Yes No
 
For site # (s):
 
Freezer:
Yes No
 
For site # (s):
 
Centrifuge Available:
Yes No
 
For site # (s):
 
Radiology Available:
Yes No
 
For site # (s):
 
Secure Drug:
Yes No
 
For site # (s):
 
Neuropsych Testing:
Yes No
 
For site # (s):
 
Types of Neuroimaging equipment
 
   
 
Additional Equipment
Internet connections:    
Dial-up for site #(s)
 
Broadband for site #(s)
 
Current Scanner(s) Enter Brand, Model # and if it has an
Automatic Document Feeder for site #(s)
 
Current Printer(s) Enter Brand and Model # for site #(s)
 
Computer connected to scanner(s) Enter operating
system for site #(s)
 
 
 
Comments
Please enter your comments here:
 
 



 
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