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PD IIS portal

Investigator-initiated study (IIS)

Application form

1. Applicant's Name *

*

2. Applicant's Email *

*
*

4. How did you hear about the online IIS application? *

*
*

6. Name of Study *

*

7. Provide key words to identify the study purpose *

*

8. How will this initiative impact clinical practice? *

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*

Principal Investigator Contact Information

10. Principal Investigator Name *

*

11. Hospital *

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*

13. Additional Investigators

Study Synopsis

*

15. Brief Description *

*

16. Study Rationale *

        Study Rationale - What are you trying to accomplish with the study and do you have references from prior studies?

*

17. Objective(s) of Study *

        Objective - What is your Hypothesis?

*

18. Primary Outcome Measure(s) *

        Primary outcome measures - what are your endpoints?

*

19. Number of Subjects *

*

20. Study Populations *

*
*

22. Patient Criteria *

        General inclusion/exclusion

*

23. Number of Sites *

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*

25. Follow-up (months)

26. Expected Study Duration (months) *

*

27. Other Companies involved in the study *

*

Equipment

*

*

30. Capital equipment used:

*

32. Philips products requested as part of the study:

*

35. Name of core lab

36. Publication and/or Podium Plan *

*

Attachments

 

Please upload the following documents with your IIS application (In PDF Format):

 

  • Official letter from managing director of hospital or employee requesting a grant of Philips
  • Current CV of Investigator leading the research, dated and signed (please remove all sensitive info before uploading, i.e., DOB, Social and Family members)
  • Draft protocol or at minimum a study synopsis ( Preliminary data (if available), Study design, Methods, Statistical plan, Study timeline (Expected Start Date/First patient in, End recruitment, Last Patient out, Data Locked, Final report/Publication) )
  • Details on the expected costs leading to the budget requested

 
Must be in PDF or ZIP Format. Should be less than 10 MB. If more than 1 PDF, please compress into zip.

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点击链接，您将离开皇家飞利浦医疗科技（“飞利浦”）官方网站。本网站上出现的任何第三方网站链接仅为提供便利，并不代表对这些链接网站上提供的信息具有任何从属关系或认可。飞利浦不能代表或保证任何第三方网站或其中包含的信息。

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