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1. In which area of the portal would you like to appear?
Service Providers
2. Enter the name of the Service Provider - Organisation Name
3. Main Service Category
Accrediting Agency
Clinical Development Consulting
Clinical Research Organisation
Clinical Trial Administration
Clinical Trial Insurance
Clinical Trial Site
Comparator Drug Supply
Compliance and Auditing
Contract Research Service
Digital Services Marketing
Government
Industry Peak Body
Intellectual Property Protection
Licensing and Commercialisation
Product Development
Regulatory Consultancy
Research Institute
Statistics and Data Development
Supply Chain
Tax and Regulatory Advisor
Training and Education
3. Enter the contact name of the Service Provider - (Title, First Name, Last Name)
4. Contact person email address
5. Contact person phone number
6. Your Service Provider web site address
7. Building/Floor/Room/Suite
8. Street name and number
9. Additional address information
10. City
11. State
12. Postcode
13. Country
14. GPS location of your site - GPS Location 1
15. GPS location of your site - GPS Location 2
16. Life Sciences Queensland (LSQ) Member
- None -
Yes
No
17. Select the language of the main content of the item. If the language does not appear in the list, please select 'Other'.
- None -
English
Other
18. Services offered by your company
- None -
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
Compliance and Auditing
19. Please provide a short, Plain English description of your service for marketing purposes.
20. Please provide the list of Therapeutic Areas for your 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
21. Please list any sub-therapeutic areas( use ; to separate fields)
22. Any other areas of expertise?
23. Has your Service been audited?
- None -
Yes
No
N/A
24. If your Service has been audited, please select all relevant types.
- None -
FDA ( Food and Drug Administration)
TGA ( Therapeutic Drug Administration)
CRO ( Clinical Research Organisation)
Sponsor
Other
25. Please provide additional information not captured in other sections of the Facility Profile that you feel is important for Sponsors to know about your Facility. Please reference the section name, if applicable.
26. Do you agree to the information you have provided to be published on the Queensland Clinical Trials Portal? www.clinicaltrialsqld.com.au
- None -
Yes
No
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