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Theravance Clinical Research Trial
Site Questionnaire:

Please take a few moments to complete the following questionnaire designed to provide insight and detailed information about your capabilities. Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. If you have questions at any time about the survey, you may contact Kelly O'Conor at 312-xxx-xxxx or by email at the email address specified below.

Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.
 
 
 
Site Structure
 
 
 
Other than the principal investigator (PI), how many full-time in-practice personnel do you have in the following area? (Please enter numbers next to each below.)
 
Internal Medicine/Primary Care Physicians
 
Gastroenterologists
 
Pain Specialists
 
Other (Please specify)

 
 
 
Does your practice have the ability to search electronic medical records (EMR) to identify patients who are on long-term opiod therapy?
 
Yes
 
No
 
 
 
Does your site use email to communicate with patients about clinical trials?
 
Yes
 
No
 
 
 
How many of the physicians within your practice refer patients to the PI for clinical trials?
   
 
 
 
How many patients (in December) will you be able to enroll in the study from your site database?
 
None
 
5 or less
 
5 - 10
 
10+

 
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