Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
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
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Institution Name
*
Your answer
Hospital Contact
Your answer
Type of Institution
*
Public Hospital
Private Hospital
Charitable
Group Practice (Clinic)
Solo Practice (Clinic)
Other
Required
Town/City
*
Your answer
State
*
Choose
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
*
Your answer
Website
Your answer
Email
Your answer
Does your site have any accreditations? If yes, please list certifications/details
Your answer
How many departments does your site have? Please list them
*
Your answer
Hospital Management Contact
Your answer
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
Your answer
No. of Beds
Your answer
How many patients visit the outpatient depatment per day?
Your answer
How many patients visit the inpatient department per day?
Your answer
How many active patients does your [site/department] have (visits within past 12 months)?
Your answer
Does the site have a separate Clinical Research department?
Your answer
How many clinical research studies are currently active at your (site/dept)?
Your answer
How many physicians at your [site/dept] are currently principal investigators on clinical research studies?
Your answer
Any new Physicians willing to conduct clinical trials at your site? If yes, please list name and speciality
Your answer
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
