PRE-SITE SELECTION VISIT CHECKLIST

STUDY TITLE
NAME OF SITE INVESTIGATOR
SITE ADDRESS
SITE CONTACT INFORMATION
STUDY CODE	VISIT DATE
SITE PERSONNEL PRESENT	ROLE
SITE MANAGEMENT ORGANIZATION (SMO) REPRESENTATIVE PERSONNEL

INVESTIGATOR INFORMATION

EXPERIENCE IN SPECIALTY in years
NUMBER OF TRIALS COMPLETED
NUMBER OF TRIALS ONGOING
EXPERIENCE IN CLINICAL TRIALS (PAST)	COMPETITIVE TRIALS (ONGOING)
YES	NO	YES	NO

SITE ATTRIBUTES

LIST SITE POSITIVE ATTRIBUTES
LIST SITE NEGATIVE ATTRIBUTES

SITE QUALIFICATION AND RECOMMENDATIONS select YES or NO

Requalification site visit should be conducted	YES	NO
A site qualification visit has been conducted within the past year and this site is recommended for the current study.	YES	NO
I do not recommend this site.	YES	NO
This site is not suitable for this study but should be considered for others in the future.	YES	NO

Print Name of SMO Representative
Signature of SMO Representative	Date

APPROVED BY:

Print Name of Reviewer
Signature of Reviewer	Date

Print Name of Approver
Signature of Approver	Date

COMMENTS

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