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Investigator Registration for Clinical Trial/Research Database (only applicable for Investigator initiated study, non-pharma sponsor study)
A. CLINICAL RESEARCH INVESTIGATOR
Select Type of Registration
*
-PLEASE SELECT-
INDIVIDUAL
COMPANY
Full Name
*
Salutation
Dr
Prof
Mr
Ms
Others
Position
*
Hospital/Clinic/Organization Name
*
Department
*
Field of Study/Specialization
*
Address
City/Town
State
Johor
Kedah
Kelantan
Kuala Lumpur
Labuan
Melaka
Negeri Sembilan
Pahang
Perak
Perlis
Pulau Pinang
Putrajaya
Sabah
Sarawak
Selangor
Terengganu
Post Code
Contact No/Mobile No
*
E-Mail
*
Student
Masters
PhD
Others
No Applicable
B. SITE CONTACT INFORMATION
Same as above
Full Name
*
Salutation
Dr
Prof
Mr
Ms
Others
Position
*
Hospital/Clinic/Organization Name
*
Department
*
Field of Study/Specialization
*
Address
City/Town
State
Johor
Kedah
Kelantan
Kuala Lumpur
Labuan
Melaka
Negeri Sembilan
Pahang
Perak
Perlis
Pulau Pinang
Putrajaya
Sabah
Sarawak
Selangor
Terengganu
Post Code
Contact No/Mobile No
*
E-Mail
*
Student
Masters
PhD
Others
Not Applicable
Function
Assistant
Secretary / PA
Administrator
Study Coordinator
Research Nurse
Others, specify
If others
C. OTHER INFORMATION
Principal Investigator
*
Team Size
*
Estimated Budget in (RM)
*
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