Symbiorph Clinical Trialogy welcomes all the Investigator interested in clinical trial to be part of our growing database. If you are interested, please submit your information using the form below:

A. INVESTIGATOR PERSONAL INFORMATION
Name
Date of Birth
Full Address of Hospital / Institute / Clinic
City		Pin
Country		Phone
Fax		Mobile
Email		Website
B. INVESTIGATOR EDUCATION
Medical Qualification
Medical Registration No
School / Institution	Degree	Year Graduated
Post Graduation	Degree	Year Graduated
C. SITE INFORMATION
Please select one of the following options that best describes your site setting:
Hospital	Clinic		University
Other
D. IRB INFORMATION
Please select one of the following options as applicable to your site:
Local IRB	Central IRB		Site is able to use both Local and Central IRB
If your site utilizes LOCAL IRB, how frequently does the IRB meet?
Weekly	Bi-Monthly		Monthly
What is the average turnaround time for your IRB to approve studies?     Weeks
E. CONTRACTUAL INFORMATION
Do you have a department that reviews contracts?
Yes	No
What is the average turnaround time for contract review?
Can contracts be reviewed prior to IRB submission/approval?
Yes	No
Other contractual issues SCT needs to be aware of?
F. CLINICAL RESEARCH EXPERIENCE
Are you interested in conducting Clinical Trials		Yes	No
Have you conducted Clinical Trials?		Yes	No
GCP Trained		Yes	No

List the 3 most recent studies he/she acted as a principal investigator:
	Indication	No. Enrolled	Year started/ended
1)
2)
Clinical Trial Experience (check all that apply):
Phase I		Phase IIB
Phase II a		Phase IV
Phase III
Areas of Expertise

Please attach CV: