Request for Collaboration by External Organization

Section 1: External Organization Information

Organization Name:

External Organization Type:

Sponsor

Contract Research Organization (CRO)

Other (Please describe)

Primary External Organization Contact Name: (First and Last):

Primary External Organization Contact Title/Role:

Primary External Organization Contact Email:

Phone number:

Section 2: Collaboration Information

Please check the box which best indicates your interest in working with VA. If you have multiple interests or multiple trials, please complete one request for each.

Would like to discuss VA site participation in an upcoming clinical trial (i.e., study has not yet begun enrolling at any locations) sponsored by/coordinated by my organization.

Would like to discuss VA site participation in an ongoing clinical trial (i.e., one or more study sites is open to enrollment) sponsored by/coordinated by my organization.

Would like to discuss opportunities to foster collaboration/partnership between my organization and VA research. Examples may include: Portfolio discussion, VA contribution to trial development/design, etc. If this option is chosen, filling Section 3 is not necessary.

Section 3: Trial Information: SKIP if you are not reaching out regarding VA participation in a specific clinical trial.

Trial Name:

Phase of Trial:
I II III IV Other

If other, comment:

Disease Indication:

If CRO: Has this trial contract been awarded to your organization?
Yes

No

Trial Sponsor:

Principal Investigator Specialty(ies) Requirement(s) (e.g., Cardiology, Psychiatry, Radiation Oncology):

Synopsis of Trial: Please provide a brief synopsis of the trial. If a PDF version of the synopsis is available, or there are additional materials you wish to share, please submit this form and email those documents directly to PartneredResearch@va.gov.

Are there any specific site level or investigator capabilities required to participate (i.e., on site PET scan, PK sample drawing)?

Total Number of Participants to be Enrolled

Total Number of Sites Expected:

Approximately how many of these sites could be allocated to VA?

Have you begun working with any VA sites on this study to date?

Yes (If yes, please list the sites)

No

Is Enrollment Competitive? Yes No

Has Enrollment Already Begun?

Yes (If yes, complete two items below) No

How many participants are yet to be enrolled?

How many months of enrollment remain?

What Is the Estimated Final Protocol Date?

When is First Participant Anticipated ?

What is the Total Enrollment Period for the Study?

Clinical Trials Identifier (NCT Number)

Check here if not yet applicable: Not yet applicable

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