POTENTIAL INVESTIGATOR QUESTIONNAIRE           

New England Research Institutes, Inc., offers exceptional clinical research capabilities, including full Contract Research Services with clients worldwide. As such, NERI is always looking for experienced and enthusiastic investigators. If you are interested in collaborating in future clinical studies, please complete this Potential Investigator Questionnaire.

A. Investigator Contact

First Name:
Last Name:
Degree(s):
Specialty 1:
 Board Certified Board Eligible
Specialty 2:
 Board Certified Board Eligible
Facility Name:
Address 1:
Address 2:
City:
State:
 Zip/Postal
Country:
Telephone:
 ext. Fax:
Email:
  *Bold indicates required fields

B. Site Information

What type of practice do you have? (select all that apply):
        Hospital - Clinic Private Practice
        Hospital/ Academic/ University Group - Private (Single specialty)
        Research Center Group - Private (Multi-specialty)
Are you a member of a Site Management Organization (SMO)? Yes     No
   If yes, please provide SMO name:
   Are you under exclusive contract to work through the SMO? Yes     No
How many years of clinical trial experience do you have?
How many study coordinators do you have?
  How many are employed full-time?
  How many are employed part-time?
  How many coordinators are CCRC certified?
  For how many studies is each coordinator responsible?
  How many years of clinical trial experience does each CRC have? (average)
     
Does your facility have a local institutional review board (IRB)? Yes     No
  If yes, how often does it meet (i.e. weekly, monthly, etc)?
  If other, please describe
  Are you able to use a central IRB? Yes     No
Please indicate the facilities available at your institution (select all that apply)
       Research Pharmacy Centrifuge
       Secure Drug Storage Clinical Laboratory
       Secure Record Storage Freezer (-20°F)
Can your facility use a Central Lab in studies? Yes     No
Do you have high-speed internet access? Yes     No
Have you conducted studies used remote data entry? Yes     No
Have you conducted studies using web-based data entry? Yes     No
 
Year
Phase
Indication
Enrollment Commitment
# Patients Enrolled
# Evaluable Patients
Year
Study Title
Enrollment Commitment
# Patients Enrolled
# Evaluable Patients

C. Medical/Clinical Therapeutic Area(s) of Interest (select all that apply)

Experienced and interested in clinical trials in this field       Disease Category
Allergy/Immunology
Allergy
Other (specify):
Anesthesia
Pain (specify):
Other (specify):
Cardiovascular
Angina
Cardiovascular Disease
Heart Failure
Hypertension
Myocardial Infarction
Other (specify):
Critical Care Medicine
ARDS
Sepsis
Other (specify):
Dentistry
Gingivitis
Periodontal Disease
Other (specify):
Dermatology
Acne
Burns
Cellulitis
Impetigo
Psoriasis
Other (specify):
Endocrine/Metabolism
Cystic Fibrosis
Diabetes Mellitus
Hypoglycemia
Lipid Disorder
Obesity
Osteoporosis
Other (specify):
Gastroenterology
Appendicitis
Crohn's Disease
Dyspepsia
Gastroenteritis
GERD
Indigestion
Ulcer (specify):
Irritable Bowel Syndrome
Other (specify):
Genitourinary
Incontinence
Other (specify):
Gerontonology
 
Hematology
Anemia
Hemophilia
Thalassemia
Other (specify):
Infectious Disease
AIDS/HIV
Candidiasis
Hepatitis (specify):
Herpes (specify):
Intra-abdominal infection
Pneumonia, Community-acquired
Pneumonia, Hospital-acquired (nosocomial)
Skin infection
STDs
Other (specify):
Medical Devices
Cardiology
Orthopedics
Urology
Other (specify):
Nephrology
Chronic Renal Failure
Nephritis
Renal Disease
Other (specify):
Neurology
ALS
Alzheimer's Disease
Dementia
Epilepsy
Meningitis
Migraine
Multiple Sclerosis
Neuropathy
Parkinson's Disease
Sleep Disorder
Spinal Cord Injury
Stroke
Other (specify):
OB/GYN
Cervical Dysplasia
Dysmenorrhea
Ectopic Pregnancy
Endometriosis
Fertility
Gestational Diabetes
HRT
Menopause
Premature Labor
Vaginitis
Other (specify):
Oncology
Breast
Colon
Lung
Ovarian
Pancreas
Prostate
Skin
Other (specify):
Ophthalmology
Cataracts
Conjunctivitis
Glaucoma
Myopia
Retinopathy
Other (specify):
Orthopedics
Bursitis
Hip Dysplasia
Tendonitis
Other (specify):
Otolaryngology
Hearing Loss
Other (specify):
Pediatrics
Spina Bifida
Other (specify):
Podiatry
 
Psychiatry
Addiction
ADHD
Anorexia/ Bulimia
Anxiety
Bipolar Disorder
Depression
Post-traumatic Stress Disorder (PTSD)
Schizophrenia
Other (specify):
Pulmonology
Asthma
Bronchitis
COPD
Influenza
Pharyngitis
Pneumonia
Sinusitis
Other (specify):
Radiology
 
Rheumatology
Ankylosing Spondylitis
Arthritis
Fibromyalgia
Lupus
Sjögren's Syndrome
Other (specify):
Transplant
Heart
Liver
Lung
Other (specify):
Urology
BPH
Erectile Dysfunction
UTI
Other (specify):
Vascular Surgery
 

Thank you for your interest in NERI.