HD Trialfinder Listing Request Form

Complete all sections of this form, then submit the completed form and any required supporting documentation to gyohrling@hdsa.org. If you have questions about the listing request process, please call 212.242.1968 ext. 211

1. Information About the Requestor

Requestors Name *

Date of submission: * +

Phone Number *

Email Address *

Organization: *

Requestor's Position *

2. Type of Request

New Study *

Yes

No

New study site? *

Yes

No

IRB approved? *

Yes

No

If yes. please attach a copy of the IRB approval documentation. 🛈

Is the study governed by a Data Safety Monitoring Board (DSMB)? *

Yes

No

Is the study registered on clinicaltrials.gov? *

Yes

No

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.

Please upload supporting documentation. 🛈

3. Study Identification Information

Study name: *

Official study title: *

Protocol ID number(s): (Please include as many ID numbers as you know. These may include: NCT number from clinicaltrials.gov, sponsor’s ID number, or site ID number.) *

Name of study sponsor: *

Name of principal investigator: *

Study site name: *

Study site address: *

City: *

State: *

Zip Code: *

Contact name: *

Contact email: *

Contact phone: *