Call for Centres form

A. Information about the centre and contact person

Please send one form per institution only!

INSTITUTION DETAILS

Institution name*

Department*

Number & Street

Postal code*

City*

Country*

PRINCIPAL INVESTIGATOR

Title*

Dr.
Prof.

Last name*

First name*

Email*

Year of Birth*

Office Phone*

Mobile Phone*

Specialist Field*

Qualification*

I confirm I am a qualified doctor

SECOND CONTACT PERSON / STUDY NURSE

Last name

First name

Email

PREVIOUS PARTICIPATION

Has your institution already taken part in ESAIC CTN Studies?

Participated Studies*

ESAIC Membership number

(Not mandatory - however if you do have one please indicate it as this helps for future communications)

B. Choose projects

Select Project(s)*

- MOPED: Management and Outcomes of Perioperative Care of European Diabetic patients. A prospective, European, multicentre, observational cohort study Chief Investigator: Donal J. Buggy, Ireland

- ENCORE: Effects of aNesthesia in COloREctal cancer outcome trial. A prospective, multicenter, international, observational, pragmatic study. Chief Investigator: Max Bell, Sweden

ENCORE
MOPED (UK Only)

Privacy and data processing*

Your personal data will be processed by ESAIC for the sole purpose of the selected Clinical Study(ies), in accordance with the ESAIC privacy policy and may be shared with the Study(ies) National Coordinating Investigator(s). If you have any questions about your data, please contact privacy@esaic.org.

I agree with the conditions

Would you like to be contacted for future research activities (CTN,Masterclass, Mentorship,…)?*

Yes
No

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