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Enter the name of the Clinical Trial Site- Organisation Name
Enter the contact name for this Clinical Trial Site- Contact Person
If you selected Queensland Health as the Organisation name, please provide your QH Facility ID
If you selected Queensland Health as the Organisation name, please select your Hospital and Health Service (HHS).
Cairns
Central Queensland
Central West
Children’s Health
Darling Downs
Gold Coast
Mackay
Metro North
Metro South
North West
Sunshine Coast
Torres Cape
Townsville
West Moreton
Wide Bay
Services Offered by your site
Pre-clinical device design
Early Phase
Clinical trials CRO
Complementary medicines clinical trials
Complementary company
Clinical trials site
Full service CRO
Pre-clinical
GP trials
Phase 1 unit
Bench research
Investigator Initiated Trials
Satellite Site
Trial Patient Recruitment
Treatment of patients
Completion of study documentation as per ICH GCP and contract
Please provide the short promotional description of your Clinical Trial Site for marketing purposes.
Clinical Trial Site person - Title
Clinical Trial Site contact person - First Name
Clinical Trial Site contact person - Last Name
Contact person email address
Contact person phone number
Your Clinical Trial Site website address
Building/Floor/Room/Suite
Street name and number
Additional address information
City
State
Postcode
Country
Life Sciences Queensland (LSQ) Member
Yes
No
GPS location of your Clinical Trial Site- GPS Location 1
GPS location of your Clinical Trial Site- GPS Location 2
Please select the Clinical Trial Site Facility's department
Medicine
ICU
Emergency Department
Women’s and Family
Mental Health
Oncology
Radiation Oncology
Imaging
Allied Health
Pharmacy
Surgery
Haematology
Paediatric Medicine
Paediatric Oncology
Paediatric Surgical
Paediatric ICU
Please provide the list of Therapeutic Areas for your Clinical Trial Site Facility: (Select all relevant)
Animal Diseases
Bacterial Infections and Mycoses
Cardiovascular Diseases
Chemically-induced Disorders
Congenital, Hereditary and Neonatal Diseases and Abnormalities
Digestive System Diseases
Disorders of Environmental Origin
Endocrine System Diseases
Eye Diseases
Female Urogenital Diseases and Pregnancy Complications
Hemic and Lymphatic Diseases
Immune System Diseases
Male Urogenital Diseases
Mental Disorders
Musculoskeletal Diseases
Neoplasms
Nervous System Diseases
Nutritional and Metabolic Diseases
Occupational Diseases
Otorhinolaryngologic Diseases
Parasitic Diseases
Pathological Conditions, Signs and Symptoms
Respiratory Tract Diseases
Skin and Connective Tissue Diseases
Stomatognathic Diseases
Virus Diseases
Wounds and Injuries
General
Please list any sub-therapeutic areas.
Any other areas of expertise?
Please indicate the Study phase capabilities of your Clinical Trial Site.
Phase I
Phase II
Phase III
Phase IV
Device Pilot
Device Pivotal
Device Post Approval
Does your Clinical Trial Site have the capacity to conduct Clinical Trials involving GMOs?
Yes
No
If yes, which of the following? (choose all that apply)
GM products that do not contain live GMOs
Modified human somatic cells
DNA vaccines
Clinical trials involving other types of GMOs
Other
If you selected other in the previous question, please specify which other types of GMOs .
Do you have Affiliated Research Sites or Satellite Sites/Clinics?
?
Yes
No
Don't know
If you selected Yes for the previous question, please list where
What study types does your Facility have experience with?
Academic
Industry
Investigator
Government
Other
If Other was selected, please indicate which study types.
Is your Facility affiliated with a government agency or part of a government funded health service?
Yes
No
Don't know
Patient Population Demographics: (Select all that apply)
Paediatrics
Adolescents/Adults 16 and onwards
Adults 18 and onwards
Geriatrics 65 and onwards
Are there any notable factors relating to your Patient Population (e.g. First Nations populations)
