Sponsor Information

Project I.M.P.A.C.T. is an initiative of the National Medical Association to increase the numbers of African-American clinical trial investigators and subjects.

The project maintains a database of interested physicians and conducts training of physicians who want to conduct clinical trials.

Use the form below to tell us about your study or to request more information. Required items begin with an asterisk and are red.

* Study Abstract:

Begin with a brief one or two sentence title, which is the first thing a patient will see before viewing the entire listing. The abstract should provide an overview of the study, including but not limited to, the following information:
- Study Phase
- Type of Study
- Illness/Indication targeted
- Type of Treatment
- If possible, one major inclusion/exclusion criteria

Official Study Title:

* Condition:

Please use the NLM Headings Browser [MeSH] if unsure of the condition's proper name.

Study Phase:

Phase I
Phase II
Phase III
Phase IIIb/IV

Overall Recruiting Status:

	Not yet recruiting: participants are not yet being recruited or enrolled
	Recruiting: participants are currently being recruited and enrolled
	Suspended: recruiting or enrolling participants has halted but potentially will resume

* IRB Status:

	Yes, the study listing is IRB approved. I do have documentation of this approval, and upon request, I agree to provide a copy of this documentation to Project I.M.P.A.C.T.
	No, this study listing is not yet IRB approved
	No, the listing isn't IRB approved, but it does meet the FDA information sheet #29 guidelines for posting a trial online

* Detailed Study Description:

* Inclusion Criteria:

* Exclusion Criteria:

Primary Outcomes

The specific measure that will be used to determine the effect of the intervention(s)

Key Secondary Outcomes

Other measures that will be used to evaluate the intervention(s).

Intervention Type:

Drug
Gene Transfer
Vaccine
Behavior
Device
Procedure

Intervention Name

Primary Sponsor / CRO:

Secondary Sponsor (if applicable)

Funding Source

Collaborators

Identification #s

Identification numbers assigned to the protocol, including any applicable NIH grant numbers. Provide up to 5 secondary ID numbers. Example: NCI-123-45678

Overall Study Officials

Person(s) responsible for overall scientific leadership of the protocol

Study Type

Interventional
Observational

Study Start Date:

Include Month and Year

Target Number of Subjects:

Center Contact Information

* Center Name:
Contact Name:
Title:
* Address:
* City:
* State:
* Zip code:
* Country:
* Phone:
Fax:
Email:

Trial Submission Information:

Person submitting the trial if different from above contact information.

Company Name:
* Contact Name:
Title:
Address:
* Phone:
Fax:
Email:

Sponsor Information

Center Contact Information

Trial Submission Information:

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