Medpass Request For Proposal

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Request for Proposal
Thank you for the opportunity to bid on your project.
Please select the services and provide as much detail as possible so we may create an accurate estimate for you. Please e-
mail or fax this completed RFP to MedPass, attention Liliane Silber, Assistant New Business Development, at
/ +33(0) 1 40 53 81 11. Please call Liliane at +33(0) 1 42 12 83 30 if you have any questions or
would like to complete this form together.
1. Project Information
RFP Date:
Proposal Due Date:
Company Name:
Contact Name:
Contact Title:
Contact Mailing Address:
Contact Phone:
Contact Email:
Feasibility / Pilot
Post-Market
Study Type/Phase:
Other____________________________
CE Marking
Registry
Study Title:
Study Product Description:
Study Product Type:
Device
Drug
Drug/Device
Device Name:
Indication:
Device Type:
Model N° :
Notified Body:
GMDN Code:
GMDN Description:
Device Class:
Indication For Use:
2. Study Timelines
First regulatory submission Date:
First Enrollment Date:
Enrollment Duration:
(months)
Treatment / Follow-Up Duration:
(months)
3. Study Assumptions
Estimated Number of Sites:
Estimated location of Sites (list countries):
Estimated Number of Patients:
Estimated Number of Unique CRF Pages:
Estimated Number of CRFs Pages / Patient:
N/A
Method of Randomization:
Paper (envelopes)
eCRF
Number of Investigator Meetings:
Number of Teleconferences:
per month
Number of Face-To-Face Meetings:
per year
Number of Core / Central Labs:
Total Number of Site Initiation Visits:
Number of Monitoring Visits per Site:
Total Number of Close-Out Visits:
Anticipated Number of Serious Adverse Events:
MedPass Services RFP Form - October 2010
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