Site Survey






SITE FEASIBILITY QUESTIONNAIRE

Please note that this questionnaire is intended to assess interest and ability to conduct this study. Completion of this survey does not guarantee selection or participation. For questions regarding this questionnaire, please contact Sibu at 716-866-4467.  
There are only a few required questions. You may also alternatively upload a file below, and then go down and hit submit. Thank you. 

PRINCIPAL INVESTIGATOR/INSTITUTION INFORMATION

1) Your Name (Reqd):

2) Your email ID (Reqd):

Your email will not be used for any other purposes other than to reply to you....

3) Your Institution/practice(required):


  • Speciality1 (Reqd): Board certified?:

  • Speciality2: Board certified?:

  • Speciality3: Board certified?:

  • Full Address: / Phone:

    Fax:

4) Have you served as PI for any clinical research study:

  • If YES, Please list the protocol / study number :

  • Do you have supporting staff (CRC, Research nurse, Administrators for budget and contract) : Select

  • What kind of support do you expect from BNCA?:

    Full site management (site initiation to study close out)/Only clinical research coordinator/Contract/Budget negotiation and administrative support/Patient recruitment and Retention/Compliance and Monitoring/Study document archival/Trial Financial Management/Others?

  • If Others, please describe:

5) Have you served as Sub-investigator (Sub-I) for any clinical research study?:

  • If YES, Please list the protocol / study number :

6) Does the institution/investigator serve as referral center?:

  • If "Yes" to question 6, how are other subjects transferred to the institution/PI?:

7) How many sub-PIs will be assigned to this study?:

  • List all SubPIs Name and speciality here:


  • CLINICAL RESEARCH COORDINATOR (CRC) | RESEARCH NURSE INFORMATION

    8) Primary CRC?:

    • Name:

    • Highest Degree:>

    • Phone:

    • Fax:

    • Email:

    • Address: Same as PIIF NOT, address:

    8.1.) Secondary CRC?:

    • Name:

    • Highest Degree:>

    • Phone:

    • Fax:

    • Email:

    • Address:Same as PIIF NOT, address:

    9. Please provide the following information for the anticipated Primary CRC for this study:

    • How many years of clinical research experience does the Primary CRC have? Years , Months

    • How many years has the Primary CRC worked with the PI? Years , Months

    10. How will study subjects be identified at your site? (Please explain)

    11. Do you have physician referral network?

    12. Does your site have experience of working with central laboratories?

    If NO, do you foresee any problems with sending samples to study sponsor’s central labs? (Please explain):

    13. Do you have a lab onsite for specimen preparation?

    14. Do you have refrigerated centrifuge available on site?

    15. Do you have -20 and -70 freezers available on site?

    16. How well can you describe our practice/office set up?


    Thank you for taking the time to complete this questionnaire. We assure you that the information provided by you will be kept confidential and will be used only for the purpose stated for determining the feasibility of your site. The information provided on this form will not be transmitted in any manner to any one else without your permission

    Acknowledgement by Principal Investigator

    By writing my name, I, attest that the information provided is accurate to the best of my knowledge.

    .
    DATE: PLACE:


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