Investigator Background Information Form

PPD has a continuous need for qualified investigators and research sites to assist with clinical research trials. If you are an interested, experienced investigator, you may fill out and submit the automated investigator background information (IBI) form below, which will allow us to enter your information into our investigator database. This database is used as a primary source for recruiting appropriate investigators for clinical trials we conduct on behalf of our sponsors.

Information such as your medical specialty and subspecialty, phase preference and diseases of interest, is critical to PPD when we are in the process of recruiting investigators for new and ongoing clinical trials. Further, it helps ensure you are only contacted for trials in which you have an interest.

If you prefer not to submit an online IBI form, you may manually send in a copy of investigator background information form (Adobe Acrobat file, 117 Kb).

You may also update your information already in our investigator database by simply contacting us.

Please read the following authorization agreement:
Investigator Data Protection Authorization PPD is committed to respecting the privacy of its clinical research investigators. We recognize that when you choose to provide us with information about yourself, you trust PPD to act in a responsible manner. PPD has enacted internal procedures, that are reviewed and monitored from time to time to ensure that your information is used responsibly and in accordance with applicable law. These procedures require that the processing of personal data, both automated and manual, meet with the following data protection principles: • be processed fairly and lawfully • be obtained only for specified and lawful purposes, and not be processed in any incompatible manner • be adequate, relevant and not excessive • be accurate and, where necessary, kept up-to-date • not be kept for longer than is necessary • be processed in accordance with the rights of data subjects • be protected by appropriate security measures • not be transferred to third parties unless adequate level of data protection exist. Data Processing All processing of personal data is, by consent, for the purposes listed above and under the control of the data controller. Individuals have the right to: • copies of their data • correct their data • prevent processing for direct marketing • withdraw consent to processing with its consequential effects • prevent non-core purpose disclosures and • prevent trans-border disclosures to third parties where there are inadequate data protection arrangements. Trans-border data flows PPD may transfer personal data to third parties as required for the conduct of clinical studies. Personal data will only be transferred to third parties following receipt of assurance that the recipient will provide adequate data protection arrangements. Data Controller All communications, queries and subject access requests that are related to data protection issues should be addressed to Charlotte French, privacy officer at 929 North Front Street, Wilmington, NC 28401-3331, U.S., or e-mailed to ppdprivacy@wilm.ppdi.com for action or response on behalf of PPD. By clicking on "ACCEPT" below, I agree that the following information about myself may be retained by PPD in the global investigator database and individual study files, as required. • investigator name and contact information • office/practice location, type, amenities and research staff • medical specialty and patient population information • affiliation with a site management organization (SMO) and SMO information • historical and current information regarding participation in PPD projects • other relevant information to allow selection for appropriate clinical trials in the future • select financial information to allow for reimbursement of investigator grants I understand that the above data will be used for the purpose of conducting clinical trials and may be transferred to the clinical trial sponsor, FDA or other regulatory bodies. I hereby consent to PPD (the "Data Controller") the use, processing and transmission of information relating to me obtained by PPD.
By selecting this box and the "Submit Form" button, I agree to the investigator data protection Authorization.
Please fill out the following information:
(All fields required)
First name:
Middle initial:
Last name:
Institution:
E-mail address:
Phone number:
Fax number:
Mailing address: (no P.O. boxes please)
City:
State/province: (U.S. & Canada)	Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territory Nova Scotia Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
State province: (outside U.S. or Canada)
Zip/postal code:
Country:	Afghanistan Albania Algeria Andorra Angola Anguilla Antigua Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Br Virgin Islands Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Island Cayman Islands Cent Af Rep Chad Channel Islands Chile China Colombia Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Dem Rep Of Congo (Zaire) Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Fiji Island Finland Fr Guiana France French Polynesia/Tahiti Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kyrgyzstan Kiribati Kuwait Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Rep Malta N.Mariana Islands Marshall Islands Martinique Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nepal Netherlands Antilles Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Norfolk Island North Korea Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Republic of Serbia Reunion Island Romania Russia Rwanda Samoa (Amer) Samoa (W) San Marino Saudi Arabia Scotland Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka St Kitts (St Christopher & Nevis) St Lucia St. Vincent/Grenadines Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay US Virgin Islands Uzbekistan Vanuatu Venezuela Vietnam Wake Island Wallis And Futuna Islands Yemen Yugoslavia Zambia Zimbabwe
Please choose your primary general medical specialty from the list below. (select all that apply):
Aerospace medicine Allergy and immunology Anatomic pathology and clinical pathology Anesthesiology Clinical biochemical genetics, clinical cytogenetics, clinical genetics, clinical molecular genetics, and Ph.D. medical genetics Colon and rectal surgery Dermatology Diagnostic radiology Emergency medicine Family practice Internal medicine (includes specific medical subspecialties, such as cardiovascular disease, endocrinology, diabetes and metabolism and medical oncology) Neurological surgery Neurology Neurology with special qualifications in child neurology Nuclear medicine Obstetrics and gynecology Occupational medicine Ophthalmology Orthopaedic surgery Otolaryngology Pediatrics (includes subspecialties neonatal and perinatal medicine, pediatric hematology/oncology and pediatric infectious disease) Physical medicine and rehabilitation Plastic surgery Psychiatry Public health and general preventative medicine Radiation oncology Radiological physics Surgery Thoracic surgery Urology