Submitted by:        Created:    Modified:   
Brief title: RASCAL PT-TrakID #:
What's this?
Location: Columbia University IRB #:
Dept chair:
Principal Investigator
UNI: Name:
Telephone: Cell or pager: E-mail:
Clinical Coordinator
UNI: Name:
Telephone: Cell or pager: E-mail:


3. Funding Sponsor initiated
PI initiated receiving financial support from an external source
PI initiated receiving material support from an external source
Other
ClinicalTrials.gov identifier: (e.g., NCT00012345)
4. Type of study Drug
Device
Other
5. The drug/device used in this study is approved by the FDA for . . . any indication
this indication
6. Is this a multi-center study? No   Yes    Number of centers:
7. Do you anticipate your work during the course of this trial will result in patentable intellectual property? No   Yes
8. Is a Clinical Research Organization (CRO) managing the project?
No   Yes    CRO name:
CRO contact information
Name:
E-mail:
Telephone:
Fax:
Mailing address:
9. Will this study require a subcontract? No   Yes   (If "yes", a contract officer will contact you.)
Form is not yet complete.  Do not yet forward information to Clinical Trials Office.
Form is complete.  Forward information to Clinical Trials Office.