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GENERAL INVESTIGATOR INFORMATION

Please complete this page by providing investigator information and the investigator's clinical research experience. If you have questions, please email jctg@jefferson.edu

1. Investigator FIRST Name

Investigator FIRST Name

2. Investigator LAST Name

Investigator LAST Name

3. Specialty/Discipline

Specialty/Discipline

4. Sub-specialty

Sub-specialty

5. Institution Information

Institution Information Institution Name:
Affiliation:
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Investigator Email:
Phone Number:

6. Fax number

Fax number

7. Approximate number of patients you currently see at your facility in a...

	1-5	6-10	11-20	21-30	31-40	41-50	51-100	100+
... day	*Approximate number of patients you currently see at your facility in a... ... day 1-5	... day 6-10	... day 11-20	... day 21-30	... day 31-40	... day 41-50	... day 51-100	... day 100+
... week	... week 1-5	... week 6-10	... week 11-20	... week 21-30	... week 31-40	... week 41-50	... week 51-100	... week 100+

8. Do you have a patient database?

Do you have a patient database? Yes

9. Number of clinical staff on site (i.e. 3 MD's, 4 RN's)

Number of clinical staff on site (i.e. 3 MD's, 4 RN's) MD's
DO's
Physicians Assistants
Nurse Practitioners
Nurses
Medical Assistants
Study Coordinators

10. Check all that is treated at your practice

Check all that is treated at your practice ACS AIDS Arthritis Atrial Fibrillation CABG Cardiac Catherization ESRD Heart Failure	Hemodialysis HEP A HEP B HEP C HIV Hypertension Hyperthyroidism Hypothyroidism	Kidney Stones Lupus Lyme Disease Osteoarthritis Pacemaker/ICD Stroke Type I DM Type II DM
Other (please specify)

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Site Feasibility QuestionnaireExit this survey

GENERAL INVESTIGATOR INFORMATION

Site Feasibility Questionnaire
Exit this survey