Clinical Research Coordinator Intake Form
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This clinical research coordinator intake form streamlines the initial screening and enrollment process for potential study participants across various research protocols. Research coordinators can efficiently assess eligibility criteria, document participant interest in specific studies, capture essential medical background relevant to inclusion and exclusion criteria, and establish availability for study visits and procedures. The form includes sections for research history, concomitant medication review, and protocol-specific screening questions.
Designed for academic medical centers, contract research organizations (CROs), pharmaceutical company research sites, and independent research facilities, this template ensures consistent data collection for study coordinators. It facilitates compliance with Good Clinical Practice (GCP) guidelines, supports informed screening decisions, and helps match appropriate candidates to suitable research protocols while maintaining detailed documentation required for regulatory oversight and study sponsor requirements.
What's included
- Participant demographics and contact information
- Study interest and referral source
- Medical history and current conditions
- Current medication list with dosages
- Previous research participation history
- Eligibility screening questions
- Availability assessment for study visits
- Insurance information for covered studies
- Emergency contact details
- Initial consent for screening contact
Who uses this template
- Academic Medical Centers
- Contract Research Organizations
- Pharmaceutical Research Sites
- Clinical Trial Units
- Independent Research Facilities
All form fields
10 fields across 3 pages. Customize any field after signing up.
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