Questionnaire for potential new treating investigators – Parkinson Study Group

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Questionnaire for potential
new treating investigators

Date this questionnaire is completed:

MM slash DD slash YYYY

Personal Info

Full Name:

First Last Academic initials

Full Title

Name of Institution

For profit?

Yes

No

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone/Fax

Email

Questionnaire

1. Is your site a PSG site?

Yes

No

If so, what is the PSG site number?

2. Attach your CV.

Drop files here or

Max. file size: 256 MB.

3. Explain in one paragraph the principal reason you wish to join the PSG.

4. Are you salaried by an institution?

Yes

No

Name of the institution

Your title in the institution

5. Are you a general neurologist or do you subspecialize in neurology?

Yes

No

What fields of neurology do you consider your subspecialty?

6. Are you a member of the Movement Disorder Society (MDS)?

Yes

No

How long have you been a member?

7. In the past 5 years, have you attended the PSG Annual Symposium?

Yes

No

List the years that you attended.

8. In the past 10 years, have you attended any meetings of the International PD Symposia or the International Congress of Movement Disorders?

Yes

No

Please, list those you attended and the years you attended.

Meeting

Years

9. Briefly describe your experience working with PD patients.

10. How do you monitor severity of PD? That is, do you use any rating scales for PD severity? Which ones?

11. Indicate the number of PD patients you see per month in each of the following categories:

New patients who have early PD, not in need of treatment

New patients who have early PD, just in need of treatment

New patients who are beyond the early PD stage

Total number of PD patients (new and current) seen per month

12. What is the percent of your total PD patients who identify themselves as:

Hispanic/Latino, %

Please enter a number from 0 to 100.

Black or African-American, %

Please enter a number from 0 to 100.

Asian, %

Please enter a number from 0 to 100.

American Indian or Alaska Native, %

Please enter a number from 0 to 100.

Native Hawaiian or other Pacific Islander, %

Please enter a number from 0 to 100.

13. In the past 5 years, what clinical trials have you participated in?

Complete the form below for each study and complete all information.

Name of Study	Years you were involved	Actions

There are no Studies.

Maximum number of studies reached.

14. List your current clinical trials.

Complete the form below for each study and complete all information.

Name of Study	Year study started and is expected to be completed	Actions

There are no Studies.

Maximum number of studies reached.

15. List your planned clinical trials.

Complete the form below for each study and complete all information.

Name of Study	Years you plan to be involved	Actions

There are no Studies.

Maximum number of studies reached.

16. Other than what is reported above, have you ever been involved with an NIH-funded clinical trial? If so, list them.

17. To participate in any PSG clinical trials (industry, government, or foundation funded) investigators must complete a course on protection of human subjects.

Please, attach a copy of your certification.

Drop files here or

Max. file size: 256 MB.

18. List your clinical trials coordinator whom you would use for a PSG study.

First Last

Please, attach that coordinator’s current CV that includes a listing of trials in which he/she has participated.

Drop files here or

Max. file size: 256 MB.

19. To participate in any PSG clinical trials (industry, government or foundation funded) coordinators must complete a course on protection of human subjects.

Please attach a copy of his/her certification.

Drop files here or

Max. file size: 256 MB.

20. Explain how you would recruit patients for a PD study needing de novo subjects.

21. Name the geographically close PD research centers that might compete with your site for PD subject enrollment in clinical trials.

22. What is the name and address of the Institutional Review Board (IRB) to which you submit industry sponsored clinical trials?

Name

Address

Street Address City State / Province / Region ZIP / Postal Code Country

What is the name and address of the Institutional Review Board (IRB) to which you submit government or foundation sponsored clinical trials (if same as above, indicate “same”)?

Name

Address

Same as above

Street Address City State / Province / Region ZIP / Postal Code Country

22. What is your institution’s Federalwide Assurance number (FWA#)?

23. If you are selected to participate in the PSG, what institution will you use for the purposes of contracting for study payments?
(For academic institutions, this is typically your university’s grants/contracts office. For for-profit non-academic organizations, this is the individual in your organization/practice who has the authority to enter into contracts.)

For industry sponsored clinical trials:

Name of contracting Institution

Contracting Officer

First Last

Title

Complete Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Email

For government or foundation sponsored clinical trials (if same as above, indicate “same”):

Name of contracting Institution

Contracting Officer

First Last

Title

Complete Mailing Address

Same as above

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Email

24. If you are selected to participate in the PSG, do you have institutional resources for you and your coordinator to attend the annual PSG meetings without PSG financial support?

Yes

No

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Parkinson Study Group
C/O Donna Moszkowicz
Saunders Research Building
265 Crittenden Blvd, CU-420694
Rochester, NY 14642-0694

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