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Site Capability Questionnaire

If interested in being considered for Radiant Development trials, please complete the Site Capability Questionnaire.

* indicates required field.
SITE INFORMATION
Miss Ms. Mrs. Mr. Dr.
Site Contact Name:*
Title:*
Site Name:*
Address:*
City:*
State:*
Zipcode:*
Phone:* ( ) - - x
Fax:* ( ) - -
Email:*
   
Website:
IRB Type: Central IRB Local IRB
   
Have you been inspected by the FDA? No Yes
   
Was a 483 issued? No Yes
If yes, when?
   
Does your site require foreign language informed consent forms? No Yes
If yes, what language(s)?
   
SITE CAPABILITY On Site –OR– ACCESS
Access to Dry Ice On Site     Access
Access to Emergency Equipment On Site     Access
Device Study Capability On Site     Access
Dexa Hologic On Site     Access
Dexa Lunar On Site     Access
ECG On Site     Access
EDC Capability On Site     Access
Lab Freezer On Site     Access
Locked Drug Storage On Site     Access
Overnight Capability On Site     Access
Phase 1 Capability On Site     Access
Phase 2 & 3 Capability On Site     Access
Refrigerated Centrifuge On Site     Access
Separate Lab & Drug Storage On Site     Access
Temperature Alarm / Drug Supply On Site     Access
Temperature Alarm / Lab Samples On Site     Access
Temperature Log Drug Supply On Site     Access
Temperature Log Lab On Site     Access
Ultrasound On Site     Access
X-Ray On Site     Access
   
RECRUITMENT
Indicate your site’s recruitment method(s).
Primary / Secondary  
      Advertisements / Fliers
      Community Outreach
(Health Fairs, etc.)
      Electronic Database
      Manual Chart Review
      Private Practice
      Referrals
      Other:
   
SMO AFFILIATION
Is your site affiliated with an SMO? No Yes
SMO Name:
SMO Address:
SMO City:
SMO State:
SMO Zipcode:
Contact at SMO:
Phone: ( ) - - x
Fax: ( ) - -
SMO Website:
   
COMMENTS:
Provide additional information or elaborate on a specific section.
   
INVESTIGATOR CONTACT INFORMATION
Only list the address for the PI if it is different than the Site address.
   
INVESTIGATOR #1
Miss Ms. Mrs. Mr. Dr.
Name: *
Role:*
Years in Clinical Research:*
Title: *
Degree:
DDS DO MBA MD MPH NP PA
PhD RN RPH
Phone: ( ) - - x
Alt. Phone: ( ) - -
Address:
City:
State:
Zip Code:
Email: *
   
INVESTIGATOR #2
Miss Ms. Mrs. Mr. Dr.
Name:
Role:
Years in Clinical Research:
Title:

Degree:
DDS DO MBA MD MPH NP PA
PhD RN RPH

Phone: ( ) - - x
Alt. Phone: ( ) - -
Address:
City:
State:
Zip Code:
Email:
   
INVESTIGATOR #3
Title: Miss Ms. Mrs. Mr. Dr.
Name:
Role:
Years in Clinical Research:
Title:

Degree:
DDS DO MBA MD MPH NP PA
PhD RN RPH

Phone: ( ) - - x
Alt. Phone: ( ) - -
Address:
City:
State:
Zip Code:
Email:
   
INVESTIGATOR #4
Title: Miss Ms. Mrs. Mr. Dr.
Name:
Role:
Years in Clinical Research:
Title:
Degree:
DDS DO MBA MD MPH NP PA
PhD RN RPH
Phone: ( ) - - x
Alt. Phone: ( ) - -
Address:
City:
State:
Zip Code:
Email:
   
INVESTIGATOR CERTIFICATION & INTEREST
Please indicate the board certification or interest for each investigator listed above.
If an investigator is board certified in a certain area, mark the square.
If an investigator has an interest in a certain area, mark the circle.
   
Allergy 1    2    3    4
Anesthesiology 1    2    3    4
Bariatrics / Nutrition 1    2    3    4
Cardiology 1    2    3    4
Dermatology 1    2    3    4
Emergency Medicine 1    2    3    4
Endocrinology 1    2    3    4
Family Practice 1    2    3    4
Gastroenterology 1    2    3    4
General Medicine 1    2    3    4
Genetics 1    2    3    4
Gerontology 1    2    3    4
Hematology 1    2    3    4
Immunology 1    2    3    4
Infectious Disease 1    2    3    4
Internal Medicine 1    2    3    4
Men’s Health 1    2    3    4
Musculoskeletal 1    2    3    4
Nephrology 1    2    3    4
Neurology 1    2    3    4
Nuclear Medicine 1    2    3    4
OB / GYN 1    2    3    4
Oncology 1    2    3    4
Ophthalmology 1    2    3    4
Orthopedic 1    2    3    4
Otolaryngology 1    2    3    4
Pain Mgt. 1    2    3    4
Pathology 1    2    3    4
Pediatrics 1    2    3    4
Plastic Surgery 1    2    3    4
Podiatry 1    2    3    4
Psychiatry 1    2    3    4
Pulmonary 1    2    3    4
Radiology 1    2    3    4
Reproductive Health 1    2    3    4
Rheumatology 1    2    3    4
Serology 1    2    3    4
Sleep Medicine 1    2    3    4
Toxicology 1    2    3    4
Urology 1    2    3    4
Vaccination 1    2    3    4
Women’s Health 1    2    3    4
   

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