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FEASIBILITY ASSESSMENT CHECKLIST FOR
CLINICAL TRIAL SITE
Investigator Site Registration
Please provide us with updated CVs, medical license and medical research certifications of all clinical research staff at your site. This should be forwarded alongside other documents mentioned in this form to: info@bispharmclinical.com
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* Gibt eine erforderliche Frage an
Institution Name
*
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Hospital Contact
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Type of Institution
*
Public Hospital
Private Hospital
Charitable
Group Practice (Clinic)
Solo Practice (Clinic)
Other
Pflichtfrage
Town/City
*
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State
*
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Abia
Adamawa
Akwa Ibom
Anambra
Bauchi
Bayelsa
Benue
Borno
Cross River
Delta
Ebonyi
Edo
Ekiti
Enugu
FCT
Gombe
Imo
Jigawa
Kaduna
Kano
Katsina
Kebbi
Kogi
Kwara
Lagos
Nasarawa
Niger
Ogun
Ondo
Osun
Oyo
Plateau
Rivers
Sokoto
Taraba
Yobe
Zamfara
Phone Number
*
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Website
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Email
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Does your site have any accreditations? If yes, please list certifications/details
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How many departments does your site have? Please list them
*
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Hospital Management Contact
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Facilities for which information can be provided
Medical and Manpower Infrastructure
List of Departments at the Site
Ethics Committee
General Lab Services
Please list names of available consultants with their specialities e.g. (1) Dr. Cook - Internal Medicine
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No. of Beds
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How many patients visit the outpatient depatment per day?
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How many patients visit the inpatient department per day?
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How many active patients does your [site/department] have (visits within past 12 months)?
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Does the site have a separate Clinical Research department?
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How many clinical research studies are currently active at your (site/dept)?
Meine Antwort
How many physicians at your [site/dept] are currently principal investigators on clinical research studies?
Meine Antwort
Any new Physicians willing to conduct clinical trials at your site? If yes, please list name and speciality
Meine Antwort
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