FHI Clinical Site Survey

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Thank you for providing information about your research site. This survey is used for sites in various countries with different disease experiences. if some questions are not applicable for your site, they can be skipped. If you have questions or need help completing this survey, please contact jtoro@fhiclinical.com

Site Contacts

First Name

Last Name

Title

Phone

Role at Site

Primary ContactBilling ContactOther

Comments on Role at Site

Address Information

Site Address

Site City

Site Country

Site State

Site Province

Site State/Province

Site Postal Code

Nearest International Airport

EPI Vaccine Schedule

EPI Information

Do you follow the WHO EPI schedule? If not, please provide details below.

YesNoNot Applicable

EPI Vaccination Schedule (please provide a link or details below. You can also attach documentation below.)

Upload EPI Information

Training

Site Training

Training

GCPIATAOther

Other Training Information

Awareness of Availability

Would you like to hear about clinical trial opportunities? If you select, “Yes”, we will send periodic messages about upcoming trials, funding opportunities, events, or other relevant information.

What type of support does your site need to promote its availability?

Approval Bodies

Regulatory Information

Approval Body Name

Agency Type

Regulatory approval concurrent with IRB?

Overall typical Approval Time for All Bodies (number of months)

Overall Performance

Challenges and Opportunities

How would you rate the site's performance?

What are the site's strengths?

What are the site's challenges?

What are the site's greatest needs?

Please review:

By checking this box, I certify that the information submitted in this application is true and correct to the best of my knowledge.By checking this box, I agree for FHI Clinical to store information collected in this form in its electronic databases.

Academic/Teaching Hospital	Acute care
Addiction/substance abuse treatment	Community (General)
Federal	Hospital Network
Long-Term Care Hospital	Military Affiliated
Non-Federal	Other
Psychiatric Hospital	Rehabilitation Hospital
Religious	State-Run
Trauma centers/Hospitals	Trust Hospitals
Urgent Care

January	April	July	October
February	May	August	November
March	June	September	December

January	April	July	October
February	May	August	November
March	June	September	December