Va Form 10-0455 - Clinical Trial Annual Progress Report
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1
2CLINICAL TRIAL ANNUAL
PROGRESS REPORT
CLINICAL SCIENCE RESEARCH & DEVELOPMENT SERVICE
TITLE OF PROJECT
PROJECT ID
REVIEW GROUP
REPORTING PERIOD (MM/DD/YYYY)
PROJECT PERIOD (MM/DD/YYYY)
FROM
FROM
THROUGH
THROUGH
PRINCIPAL INVESTIGATOR
DEGREE(S)
NAME (LAST, FIRST, MI)
ADDRESS
CITY
STATE
ZIP CODE
E-MAIL ADDRESS
TELEPHONE NUMBER
VA MEDICAL CENTER
NAME
SITE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
E-MAIL ADDRESS
ACOS RESEARCH
TELEPHONE NUMBER
HUMAN
RESEARCH
IF EXEMPT EXEMPTION #
IF NOT EXEMPT:IRB APPROVAL DATE
SUBJECTS
EXEMPT
NO
YES
NO
YES
FULL IRB
EXPEDITED REVIEW
BY IRB
BY INDEPENDENT DSMB
DATA SAFETY MONITORING
PREVIOUSLY REPORTED
NO
YES
INVENTIONS AND PATENTS
IF YES
NOT PREVIOUSLY REPORTED
PERFORMANCE SITE(S)
OFFICE
LABORATORY
IF “NON-VA” INCLUDE ADDRESS
LOCATION
LOCATION
ADDRESS
VA
VA
CITY
STATE
ZIP CODE
NON-VA
NON-VA
VA FORM
10-0455
Page 1 of 2
JUNE 2007
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