Clinical Trials Interest Survey - US Investigators
 

Non-US Investigators, please use the International Enrollment Form


Investigator Name

Name Prefix:
MI:
Name Suffix:


Address

Name of Office/Clinic/Facility:
Country: United States

Non-US Investigators, please use the International Enrollment Form


Telephone/Fax/Email

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

Mobile Cell:
Office Fax:


Medical License

Expiration Date
(MM/DD/YYYY):
DEA Number:**
** This is a secure server.

US Managed Care Provider Information

Are you a Managed
Care Provider:		  Yes     No
Are you a UHG
Provider:		  Yes     No


Medical Specialty

If you chose 'Other' as your Primary Specialty, please list your Primary Specialty here:
ABMS (American
Board of Medical
Specialty) Certified:		  Yes  No  Eligible


Sub Specialty:

If you chose 'Other' as your Sub Specialty, please list your Sub Specialty here:
ABMS Certified:  Yes  No  Eligible


Sub Specialty:

If you chose 'Other' as your Sub Specialty, please list your Sub Specialty here:
ABMS Certified:  Yes  No  Eligible


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 "Most recent trial 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.