Join REVEAL as a Site

Please complete this feasibility survey

1. Demographic Information:

*Study Site/Institution Name:

*Principal Investigator Name:

*Site Contact Person:

*Medical Office/Practice Address:

*City/Town:

*State:

*ZIP Code:

 

*Phone Number:  

Fax Number:

 

2. Contract/Budget Contact:

*Name:

*Phone Number:  

*E-mail Address:

3. Does your site utilize a central IRB?

If no,how frequently does your local IRB meet?

 

4. Please provide an estimate of the total number of PV patients in your practice:

5. How did you estimate the total number of patients in your practice? Please check all that     apply:



Other (please specify)

 

6. Are you interested in participating in the optional blood sampling sub-study?

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