RASCAL PT-TrakID:  Brief title: 
Submitted by:        Created:    Modified:   

Principal Investigator: UNI: Name:
Telephone: Pager:
E-mail:

Clinical Coordinator:
Telephone: Pager:
E-mail:

If you receive an Agreement for review or signature, fax a copy to the CTO immediately at 212-342-2844
Please include in your fax transmission any additional information that you believe may be useful to negotiations.
If you have any questions about the Agreement or the status of negotiations, please contact CTO at 212-305-4891

1. Who is funding this clinical trial? External Sponsor   Internal Investigator/Dept
2. Did the Sponsor write the protocol? Yes      No       Jointly
     If No or Jointly, please explain:
3. Is the drug/device approved for ANY indication? Yes      No     
     If Yes, please explain:
4. Is the drug/device approved for THIS indication? Yes      No     
     If Yes, please explain:
5. Do you anticipate that any inventions will be made in the course of this study? Yes      No     
     If Yes, please explain:
6. Is this a multi-center study? Yes      No     
     If Yes, please complete the following questions:  
 
  Is this the primary site?
Yes   No
 Are you subcontracted by a primary site?
Yes   No
  Do you plan to subcontract this study?
Yes   No
 Has this study started in any other institutions?
Yes   No
     
If Yes, when?
7. Please enter anticipated timeframe below:
 
Anticipated Start:
 
Anticipated Complete Enrollment:
 
Anticipated Completion:
8. Is this a competitive enrollment trial? Yes      No     
    If Yes: By Site     By Patient      
9. Is a Clinical Research Organization (CRO) managing the project ? Yes      No     
     If Yes, please complete the following:  
 
  Name of CRO:
 
  Contact at CRO :
 
  Telephone number :
 
  Fax number :
 
  E-mail address :


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