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Basic Information
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Your name:
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Request needed by:
General Study Assumptions
Molecule:
Select a molecule
A
B
C
D
E
F
Other (please specify below)
Other Molecule:
Indication:
Protocol # (if known):
Phase:
Select phase
I
II
III
IV
Global or US:
Global
US
Number of countries if global:
Number of sites:
Number of patients:
Per patient costs needed?
Yes
No
Please provide a list of assessments or study with similar assessments:
Timeline
Timeline
Date
FPI:
LPI:
LPO:
Database Lock:
Please fill out the appropriate fields for each service requested:
Central Lab
( What’s This? )
# of lab visits:
# of safety tests:
Specialty Lab
( What’s This? )
Validated assay:
Yes
No
# of specialty test:
IVRS
( What’s This? )
# of language translations:
IRF
( What’s This? )
# of timepoints (visits):
# of scans/visit
(chest, abdomen, pelvis):
# of readers:
1
2
Oncology review:
Yes
No
% of digital images (default):
ECG
( What’s This? )
Are ECGs required?
Yes
No
Additional Comments
Any additional comments:
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