Site Information Form Name of Institution * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Fax (###) ### #### Closest Medical Hospitals Licenses * (ML, DEA, CLIA) Clinical Staff Principal Investigator(s) * Name * Specialty * License/NPI * Years of Clinical Experience * Years of Research Experience * Sub-Investigator(s) * Study Coordinators * Research Assistants * Regulatory Staff * Recruitment Staff * Research Experience Check all that apply * ADHD Alzheimer's Disease Anxiety Bipolar Disorder Depression GAD Insomnia Migraine PTSD Schizophrenia Diabetes COPD Asthma Hypertension COVID-19 Vaccines Gout Atopic Dermatitis Other Facilities & Capabilities Check all that apply Exam Rooms Consultation Rooms Lab Processing Area (CLIA Waiver) Drug Storage (double-locked, monitored) CRF Storage Monitor Rooms (with phones/copier/fax) Conference Room Central IRB Transportation Services Access to Specialists/Diagnostics Research Equipment Check all that apply Centrifuge -20°C Freezer (monitored) 70°C Locked Freezer (monitored) ECG Machine Stadiometer Other Staff Training & Certification Subject Retention Tools Check all that appl * Patient Waiting Room (TV) Snacks & Coffee Magazines/Books/Newspapers Movies/Games/CDs On-site Practice Access Other Site Demographics Sex % Male & Female Age % <18, 18-60, 60> Race % Black, White, Latino, Asian, Other Thank you!
