Investigator Sponsored Trial Form
CE Provider / Course Sponsor (if applicable)
Please enter the contact information for the accredited CE provider for the course.
First Name:
Last Name:
Title:
Email Address:
Phone:
Other relevant individuals for contact:
Preliminary Study Title:
Objective:
Number of Patients:
Number of Sites:
Study Design:
Inclusion/Exclusion Criteria:
Dosing schedule of study drug(s):
Primary and/or secondary endpoint(s):
Timeline (estimated time from recruitment to study report completion):
Funding/Drug/Both:


Detailed Proposed Budget
Amount: $
Description:
Add Budget Item






Submission
Funding of your Investigator Sponsored Trial will be reviewed. Review times may vary, however typical review times will be around 2-3 weeks. You may check the status by e-mailing us at IST@americanregent.com.
Please utilize a Computer for form submission
To complete this form, you will not be able to use a mobile device. Please utilize a Computer for form submission.
Thank you.


© 2017, American Regent, Inc., A Luitpold Pharmaceuticals, Inc. Company
PP-AS-US-0014     4/2017