Fellow of the APCR Application

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Application Questionnaire

Question 3

• Have you participated as PI or Sub-investigator in an ongoing or a completed study?
• -- Select -- Yes No
• Please indicate number of examples you wish to provide: (Provide up to 5 examples)
• -- 0 -- 1 2 3 4 5

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Question 4

• Are you a member of a Medicines Development Team or Medical Director of a Clinical Research Site or Research Program?
• -- Select -- Yes No

• Program/Site/Team Name
• Year of Work

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Question 5

• Do you hold an Academic Position in Clinical Research?
• -- Select -- Yes No

• Position Name
• Rank
• Faculty Appointment

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Question 6

• Do you have a Leadership role in professional associations related to clinical research or editorial boards?
• -- Select -- Yes No

• Professional Society Name
• Editorial Board Name
• Role
• Role Start Year

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Question 7

• Do you Work in Regulatory agencies related to clinical research and Medicines Development?
• -- Select -- Yes No

• Agency Name
• Agency Start Year

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Question 8

• Have you fostered clinical research/medicines development in the community?
• -- Select -- Yes No

• Program Name
• Nature of Your Involvement (less than 50 words)

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Question 9

• Have you published in Peer reviewed journals?
• -- Select -- Yes No
• Please indicate number of publications you wish to provide: (Provide up to 5 publications)
• -- 0 -- 1 2 3 4 5

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Question 10

• Please list Awards and Recognitions for contributions to clinical research.
• If no awards/research, please enter “None”

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Question 11

• Have you made Presentations to national/international conferences?
  
• -- Select -- Yes No
• For each type listed below, please indicate the number of examples you wish to provide (up to 3 per type)

• Please indicate number of Poster examples:
• -- select -- 0 1 2 3

• Please indicate number of Workshop/Symposium examples:
• -- select -- 0 1 2 3

• Please indicate number of Plenary Session examples:
• -- select -- 0 1 2 3

• Please indicate number of Course examples:
• -- select -- 0 1 2 3

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Question 12

• Please provide examples of Innovation: (Include name of product/process and year for each example)
• If no innovation(s), please enter “None”

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Question 13

• Please list Clinical Research Training Certificates: (Include name of organization and year certified for each certificate)
• If no certification(s), please enter “None”

Question 14

• Please list other Advanced Degrees: (Include degree/diploma and year for each)
• If no degree(s)/diploma(s), please enter “None”
• Please list Board Certification(s): (Include certification(s) and year(s) certified for each)
• If no certification(s), please enter “None”

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Question 15

• $100 Application Fee: (due at time of submission)