What investigators from your site would be interested in being included in our investigators database?

Please provide your site's contact information:

Address Phone Number

What are their therapeutic specialties?

Can your site handle Adult Patients? Yes
No

Can your site handle Pediatric Patients? Yes
No

How many Study coordinators are available at this site?

Is your site affiliated with an SMO?

What is your typical turnaround time for contracts?

At your center, would the site use Local or Central IRB? Local
Central

If "Local", please estimate a turnaround time to obtain IRB approval:

At your site, can the study drug be kept refrigerated and secured at the pharmacy/site before dispensation? Yes
No

Are there any centers that you would recommend for inclusion in our investigator database ?

Please provide the name and the contact details of the person that completed the questionnaire in case of further questions or need for clarifications

Coordinator Name: