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* 1. If your application is selected to be a part of the WinR Clinical Trials Incubator, you will be expected to accomplish the following tasks (note: you will be mentored through these activities):


Prior to starting Clinical Trial activity:

  1. Attend required WIO Clinical Trial Webcasts (live or archived)
  2. Pass Good Clinical Practice (GCP) Training (on-line)
  3. Pass Ethical Training for Clinical Trials (on-line)

During Clinical Trial Activity:

  1. Fill out all Clinical Site Feasibility Surveys in a timely fashion (<2 weeks)
  2. Work with a Central IRB or your Institutional IRB in a timely fashion 
  3. Create source documents specific to a given study
  4. Develop Standard Operating Procedures (SOPs) for your study site
  5. Obtain staff and equipment certifications prior to starting any clinical trial
  6. Commit to recruiting at least 2 patients into any active clinical trial 
  7. Follow and retain patients until study end
  8. Keep study records for 10 years

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* 2. Name:

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* 3. Degree(s):

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* 4. Pronouns:

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* 5. Email address:

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* 6. Years in practice:

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* 7. Percentage of time seeing patients in a Retina clinic:

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* 8. Primary Practice name and address for main office (where study activity is to take place):

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* 9. Type of Practice (group vs. solo, private vs. PEG vs. academic, retina only vs. multi-specialty):

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* 10. Number of offices:

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* 11. Number of other retina specialists in your practice:

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* 12. Days in week at your intended Study Office:

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* 13. Number of patients seen in a typical day (average over all offices):

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* 14. Does your practice currently have Retina Clinical trials?

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* 15. Does your practice currently have Clinical trials in another sub-specialty?

If the answer to the above 2 questions is “no”, please answer yes/no/unsure to the following:

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* 16. Do you have space for a Clinical Trials Unit?

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* 17. Do you have the ability to hire a dedicated clinical studies coordinator?

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* 18. Do you have the funds to buy equipment required for basic clinical trials (eg. EKG machine, defribrillator, refrigerator, freezer)?

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* 19. Please describe any past experience you personally have with Clinical Trial Research:

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* 20. Please describe any current or past research mentors:

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* 21. Please describe your interest in clinical research in less than 200 words.

Please send a copy of your CV to sam.zerang@asrs.org

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