Drexel University College of Medicine

New Clinical Trial Agreement (CTA) Request for CRG Review

Complete the following information:
^* - required field

Attachments

CTA (MS Word format)^*:

Protocol^*:

Budget (Excel, Word or PDF)^*:

ORBudget included in body of Clinical Trial Agreement

Investigator/Coordinator Information

Principal Investigator^*:

Department^*:

Department Code^*:

Clinical Research Coordinator^*:

Sponsor Information

Sponsor Name^*:

Contract Contact Name^*:

Contract Contact Address:

Contract Contact Address 2:

Contract Contact City/State/Zip:

Contract Contact Email^*:

Contract Contact Phone^*:

Budget Contact Name^*:

Budget Contact Email^*:

Budget Contact Phone^*:

Name of Clinical Research Organization:

Study Information

Title^*:

Date/Expected Date of IRB Submission:

Will the study take place in any facilities owned by Tenet?^*
YesNo

Will Tenet services or personnel be used to conduct the study?^*
YesNo