ABC Clinical Trials Network Site Information Questionnaire

Thank you for taking about 10 minutes to complete this survey to join the Association of Black Cardiologists' (ABC) Clinical Trials Network (CTN). The purpose of this survey is to gather information about ABC members' and partners regarding clinical research interests and capacity.

Membership in the ABC CTN is open to investigators regardless of their ABC membership status, is no-cost and one can discontinue at any time. We believe you will find the ABC CTN to be a great asset to your clinical trial involvement!

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* 1. Please Provide Investigator's Contact Information

First Name

Middle Initial

Last Name

Practice Name

Address 1

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Work Number

Mobile Number

Fax Number

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* 2. Are you a member of the ABC?

Yes

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* 3. Do you wish to become a part of the ABC Clinical Trials Network?

Yes

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* 4. Do you wish to be contacted about clinical research training opportunities?

Yes

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* 5. Suffix (check all that apply)

DPM

PhD

Other (please specify)

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* 6. Education

1st Degree

2nd Degree

3rd Degree

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* 7. What is your medical specialty? (Check all that apply)

Cardiology

Family Medicine

Internal Medicine

Nephrology

Other (please specify)

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* 8. What type of practice do you have?

Solo

Group

HMO

Hospital-Based

Academic Center/University-Based

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* 9. If you have Sub-Investigators who work with you, please list their names.

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* 10. Which of the following best indicate your research interests? (Check all that apply)

Basic

Clinical

Translational

Comparative Effectiveness Research (CER)

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* 11. What type of trials interest you? (Check all that apply)

Hypertension

Diabetes

CHF

Dyslipidemia

CAD/ACS

Arrhythmia

Basic Science

Device Trials

Other (please specify)

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* 12. Do you have Clinical Research Coordinators (CRCs) who work with you?

Yes

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* 13. Please provide the contact Information for the primary CRC.

Name

Phone

Mobile

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* 14. What type of community does your practice serve?

Urban

Suburban

Rural

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* 15. What type of IRB do you use?

Central

Local

Both

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* 16. How often does your local IRB meet?

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* 17. How much time in advance do start-up packets need to be submitted to the IRB?

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* 18. Do you want to be contacted to participate in clinical trials?

Yes

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* 1. Please Provide Investigator's Contact Information

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* 2. Are you a member of the ABC?

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* 3. Do you wish to become a part of the ABC Clinical Trials Network?

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* 4. Do you wish to be contacted about clinical research training opportunities?

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* 5. Suffix (check all that apply)

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* 6. Education

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* 7. What is your medical specialty? (Check all that apply)

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* 8. What type of practice do you have?

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* 9. If you have Sub-Investigators who work with you, please list their names.

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* 10. Which of the following best indicate your research interests? (Check all that apply)

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* 11. What type of trials interest you? (Check all that apply)

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* 12. Do you have Clinical Research Coordinators (CRCs) who work with you?

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* 13. Please provide the contact Information for the primary CRC.

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* 14. What type of community does your practice serve?

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* 15. What type of IRB do you use?

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* 16. How often does your local IRB meet?

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* 17. How much time in advance do start-up packets need to be submitted to the IRB?

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* 18. Do you want to be contacted to participate in clinical trials?

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* 19. How many industry sponsored clinical trials have you conducted in the last 5 years?