PI Preferred Network

    Physician Information
    Are you currently partnered with Effectus on a Patient Identification and Consultation Program?*
    YesNo, but I have previously partnered with Effectus on a Patient Identification and Consultation ProgramNo, but I have previously completed exploratory research surveys for EffectusNo, I have never partnered with Effectus
    Full Name*
    Degree*
    Specialty*
    If "Other" above, specify Specialty
    Phone Number (Cell)*
    Phone Number (Office)*
    Email Address*
    Fax Number
    Practice Information
    Practice Name*
    Practice Address 1*
    Practice Address 2
    Practice City*
    Practice State*
    Zip Code*
    Practice Country
    Practice Website URL
    Practice Setting Type
    Size of Practice
    Experience
    Are you currently a PI or sub-I for a clinical trial?*
    YesNo
    Research Experience by Therapeutic Area (select all that apply)*
    Allergy/ImmunologyAnesthesiologyAudiologyCardiologyDermatologyEmergency MedicineEndocrinology/MetabolismFamily MedicineGastrointestinalGeriatric MedicineGynecology/ObstetricsHematologyInfectious DiseasesInternal MedicineNephrology/UrologyNeurologyOphthalmologyOrthopedicsOtolaryngologyPathologyPediatricsPreventative Medicine/RehabilitationPodiatryPsychiatry/PsychologyPulmonology/RespiratoryRheumatologyRadiologySports MedicineSurgeryOther (Please List)
    If "Other" above, specify Therapeutic Area
    Number of years of experience in Phase 1*
    Number of years of experience in Phase 2*
    Number of years of experience in Phase 3*
    Number of years of experience in Phase 4*
    Number of trials conducted in past 2 years*
    Number of trials currently conducted at your office
    Type of IRB used*
    Training
    Which of the following do you have recent documented training on? (select all that apply)*
    Principal InvestigatorGood Clinical PracticesGood Laboratory Practices for Non-clinical StudiesGood Manufacturing PracticesHIPAAElectronic Records and Electronic Signatures
    Additional Information
    Upload CV

    Terms & Conditions

    Please read the following terms and conditions. By opting-in to the Effectus PI Preferred Network, you consent to your personal information being processed by or on behalf of Effectus for the purposes set forth below.

    Healthcare providers who reside in the state of Vermont are ineligible for participation.

    1. The purpose for your submitting the requested information in this form is to allow Effectus, LLC, our affiliates, partners or sponsors to evaluate your level of qualification as a Principal Investigator on an Effectus study, to identify potential clinical trials to match your qualifications as an Investigator and for other related purposes. Effectus, LLC retains the rights to this database and the information contained in it. You further accept that you will not be compensated for providing the requested information.

    2. If you are a representative providing information on behalf of another person or institution or site, you represent and warrant that you have been duly authorized to submit the requested information on that person's behalf. You agree not to submit information about any person other than as you have been properly authorized and not to impersonate any other person.

    3. You give permission to Effectus, LLC, our affiliates, partners or sponsors to check and verify any of your information. You also agree that Effectus, LLC can contact you should we need further information related to your registration on this site. You agree that any misrepresentation or inaccuracy in the provided information may lead to removal from the Effectus PI Preferred Network database. Providing the requested information does not guarantee that Effectus, LLC will match you as an Investigator for a clinical study.

    4. Your information may be shared among our affiliates, partners or sponsors in the United States solely for this purpose. Effectus, LLC may be required to disclose this personal information based on any applicable laws. Effectus, LLC reserves the right to make disclosures of your submitted information to the extent that it may be required to do so by law, rule, regulation, subpoena, order, decree, decision or other legal process.

    5. Effectus, LLC will retain your information only for the time required to fulfill the purpose for which it was collected and in order to comply with applicable laws and regulations.

    6. You agree to be contacted by our representative in the event that you are identified as a potential match for a future Effectus, LLC study. You further agree to be provided with information and updates on activities, products and services related to clinical trial involvement. You can decide at any time not to be contacted or wish to cancel your registration by sending us an email at info@effectusctr.com.

    7. Effectus, LLC reserves the right to modify or alter these Terms and Conditions at any point in time and will notify you of any such changes. Your failure to object to any such modifications within Ninety (90) days shall indicate acceptance of the changes or modifications.

    8. Effectus, LLC will use industry best practices and standards to protect the security of the information you have provided but due to the evolving nature of electronic systems security, Effectus, LLC disclaims all warranties and or liabilities in connection with the security or confidentiality of the database and data you have provided. You hereby waive any and all claims against Effectus, LLC, its affiliates or partners with respect to the above.

    9. These Terms and Conditions shall be governed by and construed in accordance with the laws of the United States of America and the State of New Jersey, without regard to conflicts of law.

    In addition, be sure to review your entries in this form prior to submitting the information to ensure the accuracy of the data provided.