American Burn Association

	About ABA Governance History Committees & SIGs Awards Membership Past Presidents International Outreach Legislative Agenda Health Policy News and Activities Educational Resources Awards FAQs Burn Awareness Week About IAC Accomplishments IAC Members Membership Application About Verification Guidelines Verified Burn Centers Publications Educational Resources Coding Q&A Newsletter Burn Incidence Fact Sheet Job Channel Other Meetings Links

Site Eligibility Form

ABA MCTG Site Eligibility Form

Investigator Information

Investigator:

Certifications Held:

Address1:

Address2:

City,ST Zip:

Email:

Phone:

Fax:

Coordinator Information

Name:

Certifications Held:

Email:

Phone:

Facility Information

Facility Type:

Tertiary Care

Community Hospital

University / Teaching Hospital

VA Hospital

Research Center

Institution Name:

Address1:

Address2:

City,ST Zip:

ABA Verified?

Yes No

# of Burn Unit Beds :

# Acute Adult Admits/year :

Pediatric Admissions?

Yes No

# Acute Pediatric Admits/year:

Has your institution participated
in any multicenter trials in the
past 2 years?

Yes No

If yes, please describe:

Have you been audited or participated
in a clinical trial that was stopped
before planned completion?

Yes No

If yes, please describe:

Have you participated in a
Department of Defense sponsored
multicenter trial before?

Yes No

If yes, please describe:

Do you have a research coordinator
available to collect data on a
daily basis?

Yes No

Is there electronic data recording
capability (i.e. laptop or PDA) at
your facility?

Yes No

Does your site have a
Human Subjects Review Board?

Yes No

What is the average turn-around
time for a prospective study
approval by your Human Subjects
Review Board?

What is the average turn-around
time for a prospective study approval
by your Contracts Office?

Completed by:

Completed date :

(mm/dd/yy)

The American Burn Association Web site contains general information for burn care professionals. The ABA Web site is not intended to respond to requests for medical information, and the ABA is unable to respond to requests regarding personal medical concerns related to burn injuries. Your physician is the best source for information related to initial treatment, ongoing care, and follow-up issues for burn injuries. If you do not have a physician, please contact the physician referral service at your local burn center or hospital. © copyright 2005 American Burn Association