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Investigator Form

Section A: Demographics
1. Name :
2. Gender :
MaleFemale
3. Date of Birth :
4. Qualification :
5. Name of Hospital/
     Clinic/Org :
6. Designation :
7. Postal Address:
8. Pin Code :
9. Mobile :
10. Telephone :(Optional)
11. Email1 :(required)
12. Email2 :(Optional)
 
Section B: Infrastructure
 
Q1: Type of Set-Up:
HospitalClinicsResearch CentresOthers, Specify
GovernmentPrivateSemi-Private / Corporation
    Number of Beds:
ICU Set-up:
YesNo
Q2 : Do you have?
Molecular Laboratory SetupDiagnostic Laboratory Setup  Access to Diagnostic Centre  Others, Specify

Q3 : Do you have an access to Institutional Ethics Committee? :
YesNo
a: If Yes, Name of IEC ?
b: How often does the IEC meet? :
 
 
Section C: Research Interest
Q1: What are the reasons for which you wish to participate in research studies? (Multiple answers allowed):
Q2: Areas of Research Interest in Respiratory Medicine :
Q3: How many academic research projects have you started in the last 1 year?
01-5>5

a. Number of academic research studies done in the last 5 years?
Q4 : Have you ever conducted any clinical trials? :
YesNo
a. If yes, number of pharmaceutical sponsored clinical trials done in last 5 years?
Q5 : Have you ever presented any original research work at any conference? :
YesNo
Q6: On an average, how much time are you willing to dedicate to research work in a week?
Q7: How many students/assistants/co-ordinators do you have to conduct research?
01-3>3
Q8: Latest Four (4) Publications :
 
 
 
 
Section D: Patient Pool
Q1: Do you maintain a database of patients? :
YesNo
a: If yes, please indicate the type of database:
Paper BasedElectronic Based
Q2: Please indicate the size of database for following disease :
Diseases
YES
NO
No. of Patients in your Database
Asthma
YesNo
COPD
YesNo
IPF
YesNo
Bronchiectasis
YesNo
Pulmonary Tuberculosis
YesNo
Any Other Diseases, please specify:
 
 
Section E: Diagnostics


Q1: Which of the following diagnostics you have access to ? (Referrals to government/private diagnostics centres are acceptable if you have OPD setup)
 
YES
NO
COMMENT
a: Laboratory Investigations (Blood)
YESNO

b: X - Ray
YESNO
c: HRCT
YESNO
d: MRI
YESNO
e: IOS (Please specify the make/company in the comment box)
YESNO
f: DLCO (Please specify the make/company in the comment box)
YESNO
g: Body Plethysmography (Please specify the make/company in the comment box)
YESNO
h: Spirometer (Please specify the make/company in the comment box)
YESNO
i: PEFR
YESNO
j: 6 Minute Walk Test
YESNO
k: Treadmill Exercise Testing (Please specify the make/company in the comment box)
YESNO
l: Sputum Induction & Processing
YESNO
m: Sputum AFB
YESNO
n: Skin Prick Test
YESNO
o: Bronchial Challenge Test
YESNO
p: BAL Samplings
YESNO
q: Lung Tissue Samplings
YESNO
r: Others (please specify)
YESNO