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Physician Feasibility Questionnaire

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The following questions will provide the information necessary to determine the feasibility of conducting research in your practice.

RESEARCH FEASIBILITY QUESTIONNAIRE : Physician / Group Practice

Date:

Practice Name:

Specialty:

Practice Street Address:

Practice City, State Zipcode:

Satellite Offices:

PRIMARY CONTACT :

Name:

Telephone:

Fax:

Email:

PHYSICIAN(S) :

Physician Name	Research Experience (Y/N)	Interest Level (High/Low)	Areas of Research Interest

RESEARCH GOALS :

What are your specific goals for participating in research ?

RESEARCH EXPERIENCE :

Physician Name	P.I. or Sub-I.	Study Name	Sponsor	Dates

Patient Population Within Your Practice :

Please include patients of all physicians who will be participating in clinical trial research:

Total No. of
Active Patients

Total No. of
Office Visits per Year

Total No. of
Patient Visits per Week

Patient Ages as Percent of Practice:

0 - 5

6 - 12

13 - 18

19 - 40

40 - 65

Over 65

Are there any unique features about your practice that might help or hinder research?

TOP DIAGNOSES ( Do not use CPT or ICD-9 Codes) :	No. Occurrences per Month

TOP PROCEDURES ( Do not use CPT or ICD-9 Codes) :	No. Occurrences per Month

OTHER POTENTIAL PATIENT POPULATIONS:

Are there other practices in the area with which you have a good relationship and which could serve as a source of referrals for patients participating in research? Yes or No ?
If Yes, please describe:
Please provide the following information about your community so that we can assess the potential for recruiting patients from the community for studies with advertisements:
Describe / comment on the demographics of your community in each of the following areas:
4 approximate population of your community
4 age (e.g., large retired population, etc.)
4 race/ethnicity
4 education levels
4 income levels
4 religion
4 unemployment
Additional Questions
List the top 3-5 employers in your community:
What percent of your community has health insurance?
What are the common health problems in your community?
Are there any cultural barriers to using traditional medical care and/or participation in research?
Are there any unique features about your community that might help or hinder research?

HOSPITAL AFFILIATIONS :

Hospital	Medical Staff Credentials

OFFICE / FACILITY :

Assessment of Office Space	Yes or No
Is there additional space to accommodate research patient visits?
Is there a locked area for drug storage?
Is there a lab area?
( Clinical Lab) CLIA waiver?
Is dry ice available for shipping?
Is a locked refrigerator available?
Is there a temperature log procedure?
Is space available for study related document storage?
Are medical records electronic?
Is the patient database searchable by diagnosis?

Do You Have
Additional Questions or Comments for Us?

Once we have reviewed your feasibility questionnaire, a member of the Discovery Alliance development team will contact you to arrange a time to further discuss your expectations and goals.

Visit the Discovery Alliance website for more details on our clinical trials management services