Site Feasibility Questionnaire

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
*
2. Investigator LAST Name
*
3. Specialty/Discipline
4. Sub-specialty
*
5. Institution Information
*
6. Fax number
*
7. Approximate number of patients you currently see at your facility in a...
1-56-1011-2021-3031-4041-5051-100100+
... day
... week
*
8. Do you have a patient database?
*
9. Number of clinical staff on site (i.e. 3 MD's, 4 RN's)
*
10. Check all that is treated at your practice
Powered by SurveyMonkey
Check out our sample surveys and create your own now!