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CenTRE REQUEST VISIT FORM
This form is to be filled in by representative from sponsor/CRA/CRO who wish to visit CenTRE.
Please inform the site officer or study team and get verbal/written confirmation via e-mail regarding your visit prior submitting this form.
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Thank you
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Centre for Translational Research & Epidemiology (CenTRE)
https://medicine.uitm.edu.my/centre/
centremedic@uitm.edu.my
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VISITOR/S NAME & DESIGNATION
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Your answer
CONTACT NUMBER/S
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EMAIL/S
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ORGANIZATION/S
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IF YOU ARE COMING FROM OVERSEAS, PLEASE SPECIFY YOUR COUNTRY POINT OF ENTRY
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PROTOCOL TITLE & ID
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PRINCIPLE INVESTIGATOR
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STUDY COORDINATOR
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DATE,DAY OF VISIT [EX: (DD/MM/YYYY), (DAY) - (DD/MM/YYYY), (DAY)]
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SITE OF VISIT
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CenTRE Faculty of Medicine, UiTM Sungai Buloh
CenTRE Hospital Al-Sultan Abdullah (HASA), UiTM Puncak Alam
PURPOSE OF VISIT
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SITE SELECTION VISIT/SITE QUALIFICATION VISIT (SSV)
SITE INITIATION VISIT (SIV)
ONSITE MONITORING VISIT (MV)
SITE AUDIT VISIT (SAV)
OTHERS
PLEASE DESCRIBE THE PURPOSE OF VISIT
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