Clinical Trials Interest Survey - International Enrollment Form
 

US Investigators, please use the United States Enrollment Form

i3 Research, an Ingenix company, is a subsidiary of UnitedHealth Group (UHG). We are a full-service clinical research organization (CRO) with offices throughout North America, Europe, Australia and Asia and have run clinical trials in more than 45 countries. We have managed clinical studies for many of the world's largest pharmaceutical companies.

i3 Research is committed to principles of good information handling. We maintain an i3 Research Investigator Network Database, which contains information you provide us via the Web site. The information below explains our use of that data. We hope you continue to be interested in working with us and complete and return the Clinical Trials Interest Survey (Enrollment Form) so that your information in the database is accurate.

The information we request from all potential investigators is name, contact details, medical license number (or equivalent); information regarding your medical specialty, research experience, research site, research interest, and patient population; and other details pertaining to specific trials you have conducted. Once you provide us with such information, we supplement it with publicly available information about you such as information found within the US FDA databases. The i3 Research Investigator Network Database is physically located in the United States.

We use this information primarily to match your expertise and patient population with clinical trial opportunities within the US and on an international basis. You are of course under no obligation to participate in any given trial.

We may make this information available to the following classes of recipients:

  • Sponsors of clinical trials who are involved in selection of investigators
  • Potential sponsors who are interested in the feasibility of a trial
  • Regulatory agencies in the US and elsewhere
  • i3 Research affiliate companies, which may be involved in particular proposed or actual studies

This disclosure may occur in countries inside and outside the European Union (EU). Outside the EU, data protection laws may or may not apply. If they do not apply, we will respect principles of good information handling, most importantly pertaining to the security and the use of your data only for the above purposes.

There is no cost or contract requirement to be included in our Investigator Network Database. Through inclusion, investigators increase their potential for participation in clinical trials that i3 Research is under contract to manage. Investigators are not obligated to participate in any trial, but are invited to evaluate study opportunities as they are presented. The data in the database is not used for any direct marketing purposes.

Investigator Name

Name Prefix:
MI:
Name Suffix:


Address

Name of Office/Clinic/Facility:
Department:
Region/Province/Other:
Postal Code:

Telephone/Fax/Email

(please do not use hyphens (-), parentheses (()) or spaces between digits)

Mobile Cell:
Office Fax:


Medical License/Registration/Applicable Medical Registration

Number:
Expiration Date
(MM/DD/YYYY):


Medical Specialty

If you chose 'Other' as your Primary Specialty, please list your Primary Specialty here:
Sub Specialty:
If you chose 'Other' as your Sub Specialty, please list your Sub Specialty here:
Sub Specialty:
If you chose 'Other' as your Sub Specialty, please list your Sub Specialty here:


Research Experience

 Yes   No

If yes, approximately how many years of experience?

 yrs.

Have you ever done prior research with i3 Research or its legacy companies: Ingenix, Applied Clinical Communications (ACC), California Clinical Trials (CCT), ClinPharm International, InSite Clinical Trials, International Clinical Trials (ICT), Kern McNeill International (KMI), Worldwide Clinical Trials (WCT)?

 Yes   No

Please select up to 10 categories of research experience. After you have selected the category, please describe your most recent trial experience in that category. List only one trial per line.

Note: If the Start Date 'DD' is unknown, assume 01. If the Start Date 'MM' is unknown, assume 07.

 If your answer to the Research Experience question above is "Yes", then the first line of "Category of Research Experience" is required.

Most recent trial
experience
(description)		 P.I.? Phase/Device/
Inpatient		 Start Date
(MM/DD/YYYY)
Yes No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No

* Please Note: The personal information from this form is used to create an initial profile in the i3 Investigator Network Database that we will match with trial opportunities on an international basis. i3 Research manages studies on behalf of sponsors both in the United States and internationally. In order for a sponsor to make an informed decision when selecting investigators, we will disclose to them your personal information and publicly available information about you that we collect in conjunction with your submission of this enrollment form to us. We may also disclose this personal information to persons associated with the sponsors of the research projects or regulatory agencies both in the United States and internationally. By providing this personal information, you have consented to and authorized i3 Research to store, review, process, transfer, and disclose this information as outlined, until such authorization is revoked by you in writing or by phone.