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Investigator Registration
Registry Form

Use this form to submit or update your information in the Investigator Database. We will contact you when we have trials to match your capabilities and experience.

Salutation:		Other:

First Name

Last Name		Suffix:

Degree:		Other:

Group/Institute/Practice Name

Division/Department

Address 1

Address 2

Town/City

State (US Only):

County/Province

Zip/Postal Code

Country:

Please include Country & Area Code:

Phone

Fax

Cell Phone

Pager

Email Address

Site Contact Information:

If other than yourself, please advise to whom information regarding potential research studies should be sent below:

First Name

Last Name

Please include Country & Area Code:

Phone	Fax

Email Address

Designation:

Other

Ethics Committee/Institutional Review Board:

Please indicate whether you work with an EC/IRB?

Central Local Both

Research Experience:

Research Phase Experience:
(Check all that apply)

Phase I Phase II Phase III Phase IV

Current Research/Practice Setting:
(Check all that apply)

Phase I Unit Hospital Outpatient Care General Practice Research Center

Nursing Home University Hospital VA/Military Hospital/Clinic

SMO — please state name:

What age group do you treat?
(Check all that apply)

Neonatology Pediatric Adolescent Adult Geriatric

Site Capabilities:
(Check all that apply)

-70° Freezer -20° Freezer Temperature Controlled Centrifuge On-site Lab

On-site Pharmacy Ultrasound X-Ray Dexa Scanner CT Scanner

Please indicate if you have been audited by any of the following:
(Check all that apply)

Arroyo Other Sponsors Other CRO's FDA

Do you have a computerized patient database?

Yes No

Do you have any previous experience with Arroyo?
Yes No

Therapeutic Area:
Please indicate only your primary area of specialty/sub specialty:

	Primary Therapeutic Area	Specialty/ Sub-Specialty	Research Experience
1)

	Other: (please specify)
2)

	Other: (please specify)
3)
	Other: (please specify)

Do you have high speed Internet access at work?

Yes No

Do you have experience in conducting studies using Electronic Data Capture (EDC) ?

Yes No

Would you be interested in participating in studies using EDC?

Yes No

Past Experience:

Phase:

I II III IV

Setting: Inpatient Outpatient

Number Of Studies Completed

Study Conducted by:

Arroyo

Academic

Pharmaceuticals

Other Contract Research Organizations

Comments:

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