AHPBA Clinical Trials Submission

1. Contact information for person submitting this form: *This question is required.

First Name

Last Name

Credentials

Email Address

Institution

Phone

2. Title of the Study *This question is required.

3. Brief statement of purpose for the study

4. Clinicaltrials.gov #: *This question is required.

5. Are you the Principal Investigator? *This question is required.

Please provide the following:
For multi-center trials please provide information for a direct contact for the study. *This question is required.

Principal Investigator Name

Principal Investigator Email Address

Principal Investigator Institution

Principal Investigator Phone

Multi-center Trial? (Yes or No)