Clinical Trial Information Form

       Please fill in all fields below as they apply to your specific trial.
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Trial Information
Name of trial:
Purpose of trial:
Drug/Device being tested:
Possible benefit:
Sponsoring Department:
SIU Faculty Physician:
Sponsoring Company:
Number of other sites in trial:
Ending date of study:
SCRIHS Protocol Number:
Patient Information
Type of patients needed:
Age:
Health status:
Participation/Involvement Information
Number of visits required:
Length of study involvement:
Tests to be performed:
Contact Person:
Contact Phone:
Contact Email:

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