I-ACT for Children Site Network Questionnaire

Site Network Questionnaire

Site Network Questionnaire

Point of Contact

Physician Site Champion

Please identify who is completing this form

Section 1: General Information

Section 1

5. What percentage of each racial background best composes your center’s population of care (amounts in the boxes should sum to 100%):

6. What percentage of Non Hispanic/Latino ethnic background best composes your center’s population of care (amounts in the boxes should sum to 100%):

Section 2: Satellite Site Information

Section 2

Section 3: Contact, IRB & Other Review Information

Section 3

Step 1: Please identify any and all areas in which your site conducts clinical trials by checking the box to the left, next to the sub-specialty.

Step 2: Please indicate the Top 5 Therapeutic Areas (from the list above) in which your site highly performs, has highly engaged principal investigators and research staff, achieves enrollment targets in most projects, etc.

We would like to obtain performance data about the 5 key areas you identified as your site’s research strengths. Would you please provide the following:

Sub-specialty 1

Sub-specialty 2

Sub-specialty 3

Sub-specialty 4

Sub-specialty 5

Section 5: Research Team Information

Section 5

2. For the core clinical research team please indicate the number of staff

5. Of those clinical trials noted in Question 4, how many are the following

(amounts in boxes should sum to 100%)

FTEs

Section 6: Research Team Training

Section 7: Research Compliance Information

Section 8: Research Facility Information

Section 9: Investigational Drug / Product Information

Required Files

When submitting this questionnaire, please also provide the following attachments:
Drop a file here or click to upload Choose File
Maximum upload size: 134.22MB
Drop a file here or click to upload Choose File
Maximum upload size: 134.22MB
Drop a file here or click to upload Choose File
Maximum upload size: 134.22MB

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