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Investigator Enrollment and Database Form



For each investigator at your site, please complete this form so we can process you adjunct affiliation with Exodon. We appreciate your time and look forward to helping your clinical research practice grow.

Investigator/Researcher Information

Investigator Name:
Title and Degree(s):
Investigator Mailing Address:
Phone and Ext:
Fax:
E-mail:
Clinical Specialty: Board Certified: Yes No
Subspecialty: Board Certified: Yes No

Best Days of Week to Reach:

Day(s) Time(s)

Research Information

Type of Practice: Solo Group Multi-Specialty VA Research Only University Hospital

Other:

Average number of monthly patients and research subjects seen from all clinical research sites:

Using the different categories noted below, please assign a percentage to the different patient populations that you see in your practice.

Affective Disorders % Neurodiagnostic/Neurophysiology %
Autoimmune Disorders % Neuroendocrine %
Basic Science % Neurogenomics/Neurogenetics %
Brain Plasticity % Neuromuscular Disorders %
Brain Tumors % Neuropsychiatric Disorders %
Cerebrovascular Disorders % Personality Disorders %
CNS Infectious Disorders % Phase One Studies %
Cognitive Impairment and Dementia % Seizures/Epilepsy %
Eating Disorders % Sleep Disorders %
Headaches/Pain % Substance Abuse/Addictions %
Movement Disorders % Traumatic Brain Injury %
Multiple Sclerosis % Traumatic Spinal Cord Injury %
Neurodevelopmental %  

Please Estimate race, age and gender percentages of patients/subject

Caucasian % 0-11 %
African American % 12-18 %
Asian % 19-39 %
Hispanic % 40-59 %
Other % >60 %
Male % Female %

Indicate the anticipated percentage of patients/subjects that will be outpatients %
Indicate the anticipated percentage of patients/subjects that will be inpatients %
Indicate the percentage of patients that will need to go through a university IRB %
Indicate the percentage of patients that will need to go through non-university or separated clinical research IRB %

On average how many days lapse from the date of IRB submission to the IRB and EC Response

Research Specialty: (e.g., Stroke, Dementia)
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
  Preferred Phases  
  Phases: I Avg. # of previous studies
Phases: II Avg. # of previous studies
Phases: III Avg. # of previous studies
Phases: IV Avg. # of previous studies

If there is one or more Clinical Research Coordinators at your site, please include the coordinator's name: phone: #previous trials:
If you do not have a CRC available, Exodon offers clinical research support services on an as needed basis.

How many years of clinical trial experience does the clinical research coordinator have?

Facility information

Please indicate the name of each of your sites:
1.
2.
3.
4.
5.
6.
7.

Pleaes indicate by checking the box if you have daily access to:

Pharmacy:
For site # (s):


Clinical Lab:
For site # (s):


Phlebotomy:
For site # (s):

Freezer:
-20 to -70 - 70 or belo
For site # (s):


Centrifuge Available
For site # (s):
Radiology
For site # (s):
Secure Drug Storage
For site # (s):
Neuropsych Testing Types of Neuroimaging Equipment

Additional Equipment