Complete all sections of this form, then submit the completed form and any required supporting documentation to If you have questions about the listing request process, please call 212.242.1968 ext. 211
1. Information About the Requestor
2. Type of Request
New Study *
New study site? *
IRB approved? *

Is the study governed by a Data Safety Monitoring Board (DSMB)? *
Is the study registered on *
If no, please submit the following:
1. A patient-friendly summary.
 This summary should be written so that it can be easily understood by a member of the general public. Please try to avoid medical or scientific jargon. The summary should include a brief outline of the study, the question that is being addressed by the study and what will be expected of the participant during the study (e.g., number of visits to the study site, any tests or exams that will be performed, whether a care partner is needed to attend with the participant). If the study is a treatment trial, please include information about the treatment(s) being tested and their mechanism of action, if known.

2. Eligibility criteria.
Please be as detailed as possible.

3. Study Identification Information