ICON Clinical Research is currently looking into the ... - ICON plc

ICON Investigator Database Registration Form
Please complete if you are interested in becoming
an ICON Investigator
ICON Clinical Research is currently updating the data in and expanding our global investigator database.
We would very much appreciate if you could take a few minutes to complete this questionnaire and return
it, together with the signed data consent form to the fax number below:
Fax Number: Update as appropriate fax no.
For the attention of: Update as appropriate name
Alternatively you can email the completed form - send to ISPRINT.admin@iconplc.com. If you do this,
please remember to sign the last page and send a scanned copy to the email address. For additional
queries, please use this email address, or feel free to contact ICON by phone: Update as appropriatename
and phone
Investigator details
Investigator First Name:
Last name:
Name of institution
Address:
Telephone:
***e-mail mandatory field:
Fax:
Country:
Site Setting: General Hospital University Hospital/Academic Medical Centre
Private Practice Other, e.g. specialised research unit/phase 1 unit etc:
Therapeutic areas of interest
1. What is your Medical Specialisation? If you are a generalist please put internal medicine,
family practice. (mandatory field )
2. Please indicate if you have a sub-specialisation.
3. What is your main therapeutic area of interest in terms of Clinical Trials? (mandatory field )
What patient age groups do you treat? Tick all that apply
Neonates Paediatric Adolescent Adult Geriatric
Please list your specific areas of interest for clinical trials, in terms of indications / therapeutic areas
Page 1 of 3 Investigator Registration form, Version 3, 5 January 2012
Thank you for your time

ICON CLINICAL RESEARCH
Clinical Trial Experience
How many studies have you conducted in areas of interest?
Indication
# studies conucted in
the last 5 years
# studies currently
recruiting
# studies planned in the
next year
Based on the above, please provide details of your recent trial experience, please copy this sheet if you would
like to add more details
Trial details, Phase Year
started
# patients
randomized
Is it still
recruiting?
#
patients
planned
#
patients
screened
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Page 2 of 3 Investigator Registration form, Version 3, 5 January 2012
Thank you for your time

ICON CLINICAL RESEARCH
Please sign the data protection form below (mandatory) and return with this form by fax or scanned and sent
by email.
SITE DATA PROTECTION CONSENT FORM
ICON Clinical Research (“ICON”) is committed to protecting the privacy of its Clinical Research Investigators. To this end, ICON
has put in place internal procedures, including a Global Code of Conduct on Data Protection, to ensure that your personal
information (including personal information as detailed in the CV if and when collected), is processed responsibly and in
accordance with applicable data protection/privacy laws. These procedures require that personal information is processed in
accordance with the following Data Protection principles:
Data is processed fairly and lawfully.
Data is collected for explicit and legitimate purposes
Data is relevant and not excessive
Data will be accurate and where necessary, kept up to date.
Data controllers are required to provide reasonable measures for individuals to rectify, erase or block incorrect data about
them.
Data that identifies individuals must not be kept longer than necessary
Data will be kept secure
Data will not be transferred to third countries or parties unless there is adequate protection
Purpose
The purpose of ICON collecting your personal information is to enable your participation in conducting current and upcoming
clinical trials. ICON may transfer your personal information to third parties including clinical trial Sponsors, regulatory authorities,
auditors and study related personnel, as required for the preparation and conduct of a clinical trial. Clinical trial Sponsor may also
retain such personal information for the purposes of conducting and evaluating future clinical trials.
Data Processing/Rights
All data processing of personal information is by consent, for the purposes listed above. You have the right to access your
personal information or have them corrected upon request to ICON. In addition, you may withdraw your consent to processing of
your personal information at any time and request to have it suppressed, except where ICON or clinical trial Sponsor have a
regulatory obligation to retain your personal information. Please note that if you do not allow us to process your personal
information, it will not be possible for you to participate in any research conducted by ICON on behalf of the clinical trial Sponsor.
Questions
All questions, requests to access, correct or suppress your personal information should be addressed to the Global Data
Protection Officer, ICON Clinical Research Ltd., South County Business Park, Leopardstown, Dublin 18, Ireland.
I agree that my personal information (including my personal information as detailed in the CV if and when collected) may be
stored by ICON in its Global Investigator Databases and individual study files, as required:
contact details (business address, telephone, mobile, fax, e-mail address if applicable)
medical qualification
previous experience in clinical trials (indication, number of years)
previous and current information regarding participation in ICON studies
other relevant information to allow selection for appropriate clinical trials in the future
I understand that the above information will be used for the purpose of being selected to conduct and/or conducting clinical trials
and/or evaluating clinical trials.
I understand that this information may be transferred to clinical trial Sponsor. ICON locations in other countries, regulatory
authorities, auditors and study related personnel, as required.
I understand that clinical trial Sponsor may hold this personal information on internal databases for the purposes of conducting
and evaluating future clinical trials.
I further understand that transfers to such parties may result I the transfer of personal information to third countries that may not
provide for the same level of personal data protection as in my home country.
Signature:
Name (please print):
Institution:
Date:
Page 3 of 3 Investigator Registration form, Version 3, 5 January 2012
Thank you for your time