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A. Site Details

Please add the details of your clinical research site/institution where studies are conducted:

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* Country

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* State (U.S. only)

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* Province/Territory (Canada only)

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* Region, County, or Province/Territory (other countries than U.S. or Canada)

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* Site/Hospital/Institution/Practice Contact Details:

Site Name *

Division/Department

Address 1 *

Address 2

City/Town *

ZIP/Postal Code *

Phone Number (incl. country and area code) *

Website Address

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* Please complete this section based on your current research/practice setting:
(Check all that apply)

Phase 1 Unit

Stand-Alone Research Unit

Combined Research Unit/Medical Practice

University/Academic Hospital

Community/General Hospital

Private Hospital

Veteran/Military Hospital

Outpatient Clinic

Family Practice

Nursing Home

Other (please specify)

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* Is your site part of a site network/affiliation or site management organization (SMO)?

Yes

A. Site Details

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* Country

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* State (U.S. only)

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* Province/Territory (Canada only)

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* Region, County, or Province/Territory (other countries than U.S. or Canada)

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* Site/Hospital/Institution/Practice Contact Details:

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* Please complete this section based on your current research/practice setting:(Check all that apply)

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* Is your site part of a site network/affiliation or site management organization (SMO)?

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* If yes, please specify site network/affiliation/SMO name:

* Please complete this section based on your current research/practice setting:
(Check all that apply)