SITE REVIVAL CONTACT FORM

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MEDICAL CLINIC NAME:

CLINIC STAFF FULL NAME:

Please provide the name of the person completing this form.

CLINIC STAFF POSITION:

CLINIC ADDRESS:

PHONE NUMBER:

EMAIL:

CLINIC WEBSITE:

PAYMENT TYPE:

START DATE OF INTEREST:

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ASSESSMENT

1. What is the size of your clinic staff that is dedicated to working on clinical trials?

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2. How many protocol deviations or violations has your site recorded across studies over the past 3-4 months?

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3. On a scale of 1-10, how challenging is trial participant recruitment and retention at your site?(1 being the least , 10 being the most)

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4. How often does your site miss data entry deadlines?

5. Please rate your staff's competency from 1-5 across critical functions for each of the following: IP accountability, GCP protocols, safety reporting (1 less competence,2 slightly competent, 3 average, 4 above competence , 5 exceed in competence).

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6. What systems or technology is currently used for workflow/process management? How could these be improved?

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7. Which GCP or protocol areas need the most improvement at your location?

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8. What are the biggest infrastructure bottlenecks impacting performance?

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9. How many trials does the site have active as of today ?

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10.How many trials has your site failed to meet enrollment targets over the past 2 years?

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11. What are your biggest challenges with instilling accountability around IP handling?earch site ?

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12. Does the clinic have a budget set in place for Vendor training ,developing or supporting the site ?If yes, please provide the budget amount.

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13. What are the current strengths and capabilities onsite teams wish to preserve or build upon?

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14. What does site leadership deem the #1 priority objective for performance improvement through this bootcamp?

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Toll Free: 1-888-5-BERTON (1-888-523-7866), Dial 5

Local Phone: 754-238-2017

ADDRESS: 401 East Las Olas Blvd Suite 1400 Fort Lauderdale,Florida 33301

EMAIL: Admissions@BertonAcademy.com