Investigator Registration Form

SECTION-A: INVESTIGATOR & ADDRESS DETAILS

Q1. Investigator First Name:

Q2. Investigator Last Name:

Q3. Name of Institution:

Q4. Address:

Q5. City:

Q6. State:

Q7. Postal code:

Q8. Country (if using a paper version, please write in ink) : Selected CountryAfghanistanAlbaniaAlgeriaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBrazilBrunei DarussalamBulgariaBurkina FasoMyanmar/BurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongoCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominican RepublicDominicaEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench GuianaGabonGambiaGeorgiaGermanyGhanaGreat BritainGreeceGrenadaGuadeloupeGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIsrael and the Occupied TerritoriesItalyIvory Coast (Cote d'Ivoire)JamaicaJapanJordanKazakhstanKenyaKosovoKuwaitKyrgyz Republic (Kyrgyzstan)LaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgRepublic of MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMartiniqueMauritaniaMauritiusMayotteMexicoMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNepalNetherlandsNew ZealandNicaraguaNigerNigeriaKorea, Democratic Republic of (North Korea)NorwayOmanPacific IslandsPakistanPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent's & GrenadinesSamoaSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovak Republic (Slovakia)SloveniaSolomon IslandsSomaliaSouth AfricaKorea, Republic of (South Korea)South SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTajikistanTanzaniaThailandTimor LesteTogoTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsUgandaUkraineUnited Arab EmiratesUnited States of America (USA)UruguayUzbekistanVenezuelaVietnamVirgin Islands (UK)Virgin Islands (US)YemenZambiaZimbabwe
Q9. Phone Number:

Q10. Fax:

Q11. Email:

Q12. Site Setting:
General Hospital/PolyclinicUniversity/Acad Med Ctr/Ctr of ExcellencePrivate PracticeOther, e.g. specialised research unit/phase 1 unit etc (please specify)

SECTION-C: THERAPEUTIC AREAS OF INTEREST

Q14. What is your Medical Specialisation? (If you are a generalist please put internal medicine, family practice

Q15. Please indicate if you have a sub-specialisation?

Q16. What is your main therapeutic area of interest in terms of Clinical Trials e.g. Cardiology, Oncology etc? (Please put generalist if you do not have a specific therapeutic area)

Q17. What patient age groups do you treat? (Tick all that apply)
NeonatesPaediatricAdolescentAdultGeriatric

Q18. Please list your specific areas of interest for clinical trials, in terms of indications / therapeutic areas:

SECTION-D: CLINICAL TRIAL EXPERIENCE

Q46. Are you interested in Biosimilar trials?
yesNo

Please visit the following link by copying and pasting the line to the browser, if you would like to know more about Biosimilar trials.
YesNo

Q47. How many years of experience do you have conducting clinical studies according to ICH-CGP?
Years ICH-GCP clinical study experience:

Q48. Please indicate the level of ICH-GCP clinical study experience in the last 5 years as Investigator.
Number of Clinical Studies:


Q49. Of all clinical trials that you have participated in how many were:
Phase I Biosimilar trials:

Phase III Biosimilar trials:

Q50. Does your site have previous clinical study experience of blood sampling for Pharmacokinetic (PK)analysis?
No PK study experiencePK experience in 1-5 studiesPK experience in > 5 studies

Q51. Confirmation

I confirm that I am the Investigator named on Q-1 of this questionnaire and have reviewed/ completed this questionnaireI confirm that I have completed this questionnaire on behalf of the Principal Investigator at my site- Please provide your name

SECTION-E: SIGNATURE

Please SIGN this questionnaire by completing the following and then press the SUBMIT Button.