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Call for Centres form
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Clinical Trial Network
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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
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-- Select --
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PRINCIPAL INVESTIGATOR
Title
*
Dr.
Prof.
Last name
*
First name
*
Email
*
Year of Birth
*
Select one
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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
*
APRICOT
EPIMAP
ETPOS
EuSOS
LASVEGAS
NECTARINE
OBTAIN
PAIN-OUT
PERISCOPE
PLATA
POPULAR
PROBESE
MET-Repair
SQUEEZE
None
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,…)?
*
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