(نموذج 4) (Form No. 4) رقم STATEMENT OF INVESTIGATOR NAME AND ADDRESS OF INVESTIGATOR Name of principal investigator Address Commission for Health Specialties no. City Qualified area(s) of specialty Telephone no. E-mail EDUCATION, TRAINING, AND EXPERIENCE THAT QUALIFY THE INVESTIGATOR AS AN EXPERT IN THE CLINICAL INVESTIGATION OF THE DRUG FOR THE USE UNDER INVESTIGATION. ONE OF THE FOLLOWING IS PROVIDED (select one): Curriculum vitae Other statement of qualifications Does the investigator have GCP certification? Yes No If yes, attach your certification. NAME OF TRIAL SITE Name of hospital or other research facility Address City Telephone no. NAME AND ADDRESS OF ANY CLINICAL LABORATORY FACILITIES TO BE USED IN THE STUDY (in case of central lab) Name of clinical laboratory facility Address City Province/region Country Postal code NAME AND ADDRESS OF THE INSTITUTIONAL REVIEW BOARD (IRB) THAT IS RESPONSIBLE FOR REVIEW AND APPROVAL OF THE STUDY/STUDIES Name of IRB Address Registration no. at NCBE
(نموذج رقم 4) (Form No. 4) STATEMENT OF INVESTIGATOR NAME AND ADDRESS OF INVESTIGATOR Name of principal investigator Address Commission for Health Specialties no. City Qualified area(s) of specialty Telephone no. E-mail EDUCATION, TRAINING, AND EXPERIENCE THAT QUALIFY THE INVESTIGATOR AS AN EXPERT IN THE CLINICAL INVESTIGATION OF THE DRUG FOR THE USE UNDER INVESTIGATION. ONE OF THE FOLLOWING IS PROVIDED (select one): Curriculum vitae Other statement of qualifications Does the investigator have GCP certification? Yes No If yes, attach your certification. NAME OF TRIAL SITE Name of hospital or other research facility Address City Telephone no. NAME AND ADDRESS OF ANY CLINICAL LABORATORY FACILITIES TO BE USED IN THE STUDY (in case of central lab) Name of clinical laboratory facility Address City Province/region Country Postal code NAME AND ADDRESS OF THE INSTITUTIONAL REVIEW BOARD (IRB) THAT IS RESPONSIBLE FOR REVIEW AND APPROVAL OF THE STUDY/STUDIES Name of IRB Address Registration no. at NCBE
statement%20of%20investigator.docx