Physician Office Feasibility Questionnaire

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We truly appreciate your interest in collaborating with us and we kindly ask that you complete the following questionnaire. Please direct any questions to: info@imaniti.com

Principle Investigator Full Name

PI’s Primary Specialty

PI’s Email

PI’s Phone

PI’s Fax

Affiliate Site Name

Affiliate Site Address

Study Coordinator Full Name

Study Coordinator Email

Please indicate your interest in participating in this study:

Definitely not interested

Definitely interested

Clear selection

Do you (PI) have training in ICH-GCP and is familiar with applicable regulatory requirements in conducting a clinical study?

Yes

Unsure

Clear selection

Does your site have reliable Wi-Fi? Informed consent and Source documents will be electronic.

Yes

Unsure

Clear selection

Has your practice/institution ever been inspected/audited by a regulatory authority with a negative outcome?

Yes

Unsure

Clear selection

Number of midlevel providers at each location:

What staff are available at your site? Check all that apply.

Principal Investigator

Sub-investigator

Primary Study Coordinator

Study Nurse

Back-up or Additional Study Coordinator

Back-up or Additional Study Nurse

Phlebotomist

Back-up Phlebotomist

Radiology Technician

Which of the staff indicated in the question above are licensed? Check all that apply.

Principal Investigator

Sub-investigator

Primary Study Coordinator

Study Nurse

Back-up or Additional Study Coordinator

Back-up or Additional Study Nurse

Phlebotomist

Back-up Phlebotomist

Radiology Technician

Thank you for your time and interest! We will be in contact shortly.

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