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