ISARIC membership application ISARIC membership application form Network Information Network name Acronym Clinical focus What is the academic field of work? Acute Care Anaesthetics Critical Care (Medicine) Clinical / (Medical) Research Epidemiology (Emerging) Infectious Diseases Preparedness Research Public Health What is your clinical focus? Adult Maternal Paediatric Not applicable Please list (in bullet point format) the objectives of the network Trials completed? Yes No If yes, please list completed trials Access to patients? Yes No What is the number of research sites/hospitals which you have access to 1-5 6-10 11-20 21-40 41-60 >61 In the last five years, what is the clinical research experience within the Network/Organisation? Clinical trials (drug or device) Epidemiological and surveillance studies Laboratory studies Observational/sampling/non-intervention Social science/anthropology Vector studies Animal studies Other (if other, please specify) Not applicable Clinical research experience - please specify Publications (key three papers) Which type of industrial partnerships, if any, are in place for research, or the implementation of trials within your network? Academic / Industry Collaboration Industry Collaboration (e.g. favourable rates on diagnostic equipment, and / or therapeutics etc.) No collaboration with Industry (e.g. no sponsorship with diagnostics, and / or therapeutics) Countries involved (please select all that apply) Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe (Use control-click or command-click to select multiple countries) What does your network do best? Do you require any support? Advice/language on scientific rationale Data forms and core outcome measures Templates (Consent forms/ethics committee letters etc.) Dissemination: Shared Study documents across all studies, surveys circulating No support required Other, if other, please specify Please specify the support you require How did you hear about the Federation? Referral/recommendation Clinical Characterisation Protocol (CCP) Case Report Forms (paper &/ electronic) Data Platform Other, if other, please specify Please let us know how you heard about the Federation Website address Please list any other social media accounts here Contact Details Please note that the Contact Person indicated below will be considered the Board Representative for your network. Please contact the ISARIC Global Support Centre should you wish for someone else to represent the network in ISARIC’s governing body. First name and family name of the contact person representing your network: Institutional affiliation Institutional affiliation postal address Phone number Email address Is the contact point the same as the principal investigator/director (If 'No', please fill in next section): Yes No If you answered 'No' to the previous question, please provide the name of the principal investigator below Name Please confirm the Principal Investigator's Institutional Affiliation Principal Investigator's postal address: Principal Investigator's phone number: Principal investigator's email address: Are you/your organisation on social media? If so, please share the social media links/handles below Data protection & Declaration By submitting this form you agree to be bound by the ISARIC terms and conditions * The information submitted on this form is kept for the purpose of ISARIC’s membership inventory and for the dissemination of information to all confirmed members of ISARIC. All data will be kept under lock and key and stored in a password-protected database, which is accessible solely by ISARIC’s Global Support Centre. The data is stored and kept in compliance with the 2018 General Data Protection Regulation (GDPR): http://www.admin.ox.ac.uk/councilsec/compliance/dataprotection/ The declaration should be submitted by the Contact person named in Section 2. By submitting this form, I confirm that the network is committed to the purpose, mission and vision of ISARIC and will follow the obligations of ISARIC membership. To the best of my knowledge, the network fulfills the criteria for ISARIC Membership. I am authorised to submit this application on behalf of the network. Submit If you are human, leave this field blank.
