Collaborator Inquiry Form
Company Name
*
Contact Information
*
Company Website
*
Company Type
*
Please Select
Pharmaceutical Company
Biotechnology Company
Medical Device Company
Diagnostic Company
Academic Institution
Foundation/Non-Profit Organization
Clinical Research Organization (CRO) or similar
Investigator
Other (specify)
If Other: Specify Company Type
*
Company Type
Therapeutic area (select all that apply):
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COPD
Bronchiectasis
NTM
Other
Project Overview
Briefly describe your project (2-3 sentences).
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Stage of Project
Which best describes where your project is today? Select all that apply.
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Just exploring ideas/information gathering
Project/Study is planned/imminent
Project/Study is under development
Project/Study is already underway
Services Needed
Which services are you interested in? Select all that apply.
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Abstract/Manuscript development
Advisory board/panel
Biostatistics
Clinical Monitoring
Co-Branding of CME event/project
Complete CRO services
Content review for CME event/project
Contracting and dispersal of honoraria for patient or provider participation (for any activity outlined in this list)
Data management
Data visualization/dashboard
EDC development
Statistical programming
Statistical analysis plan
Full study/trial engagement
Site feasibility
Site identification
Study design
Study feasibilty
Protocol development
Protocol review and feedback
Project management
Provide recruitment for CME events/projects
Patient recruitment for CME event/project; specify recruitment goal/exclusion*
Patient recruitment for study; specify recruitment goal*
Patient recruitment for interviews; specify recruitment goal/exclusion criteria*
Patient engagement/feedback for market research; specify recruitment goal*
Other:
Patient recruitment for CME event/project; specify recruitment goal/exclusion:
*
Patient recruitment for study; specify recruitment goal:
*
Patient recruitment for interviews; specify recruitment goal/exclusion criteria:
*
Patient engagement/feedback for marker research; specify recruitment goal:
*
Budget and Sponsor Information
The COPD Foundation and Bronchiectasis and NTM Association have ongoing partnerships with industry companies to work on many of the services outlined above. To ensure we are not duplicating efforts, we need to know the sponsor (if any) for this activity. Are you working with an industry sponsor for this project?
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Yes
No
Unsure
If yes, specify sponsor:
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Has funding been secured?
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Yes
Partially
Not yet
Unsure
What is your anticipated budget for the above selected services?
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Under $20,000
$20,000-$40,000
$40,000-$75,000
$75,000-$150,000
$150,000-$350,000
$350,000-$500,000
$500,000+
Prefer to discuss
Timeline
When would you like the project to begin?
*
Within 3 months
3-6 months
More than 6 months
Flexible
Immediate; specify a deadline:
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