Resources Principal Investigator Registration Principal Investigator PI Name * Title Study ID# / Sponsor Protocol Number (if any): Study Sponsor and/or Lead Site (if Single IRB): Name of Practice / Site where Study will be performed * Relationship to Site: * Employee Other: Address where study will be performed * City * State * Zip * Phone * Email * Contact Person Name * Title * Address * Phone * Email * Department Select OneEmergencyMedicinePediatricsPsychologySurgeryOthers Specialty 1: Board Certified YesNo Specialty 2: Board Certified YesNo How many studies are you currently participating in?: How many coordinators do you have? How many are CCRC Certified? Does the PI have certification of training in Human Subjects Protection? *YesNo Additional Information Have you ever had an FDA Audit? *YesNo If Yes, what year was it done? Was a 483 issued? *YesNoN/A If Yes, Please attach file here Did you ever have any medical license issue? (ie: suspensions or probation periods) *YesNo If Yes, Please explain: Please upload an updated version of the PI’s CV, HSP training, and current Medical License.