Clinical Research Recruitment Advertising Survey

IRB Protocol Number:
Does this study require full board review? Yes No
Marketing and Communications has budget resources set aside for clinical trial recruitment, especially in the case of a trial with broad eligibility criteria but no advertising budget.
What is the anticipated date of review?

Marketing and Communications has budget resources set aside for clinical trial recruitment, especially in the case of a trial with broad eligibility criteria but no advertising budget.
In lay terms, what is the focus or goal of this study?
What will participants be asked to do?
People may be eligible for this study if they?
Will participants be compensated for time and travel? Yes No
Who is the study director or principal investigator?

Name, credential, department, division
Who is the study coordinator?

Name, department, division
Who is the study contact person?

If different than study coordinator, name, department, division, extension.
Is this study grant supported or industry supported? Grant Supported Industry Supported
For Marketing and Communications purposes only.
Does this study have an advertising budget? Yes No Budget Pending
Marketing and Communications has budget resources set aside for clinical trial recruitment, especially in the case of a trial with broad eligibility criteria but no advertising budget.
If yes, please provide an estimate for Print, Radio, TV, and Web
How many participants does this study need to enroll?
How many people do you expect to screen locally to meet your enollment target?
Will this study be promoted by an independent advertising agency arranged by the sponsor? No (please continue to next question) Yes (please list a contact name and number for that agency and skip the last section)
Contact name and number of agency:
If the agency will only provide certain advertising components, please fill out the section below for other materials the study may require, e.g. internal flyer, etc.
Please check the boxes next to the type of advertising you would like to use for this study: I prefer to have Marketing and Communications recommend advertising formats based on the information I’ve provided above Clinical Trials Office and departmental Web site listing (can be same design as flyer) Daily newspaper ad Weekly community circulars ad Internal/clinic flyer Direct mail to referring physicians On hold message Print Newsletter blurb PSU News Wires Radio spot TV spot Study brochure
I have an image I would like incorporated in the design.
Please select one: I want the designer to select an appropriate image for my review. I do not want any images on this flyer.
Will Marketing and Communications print these? (Requires two additional days for processing) If yes, please fill out the Print Request Form) Yes No
If yes, please list: Please supply a pull-day date (estimate open enrollment time)
Quantity needed:
Where they should be delivered when ready: