Investigator-Initiated Study (IIS) Application Form

Name of Principal Investigator(Required)

First Last

Title

Institution(Required)

Address(Required)

City State / Province / Region Country

Email(Required)

Phone

By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.

Other Investigators

Name of Study

Briefly describe the study. Include purpose of study, study population, and the primary endpoint. (500 word limit)(Required)

What is your hypothesis?(Required)

# of participants(Required)

# of sites(Required)

What type of support are you requesting(Required)

Financial

Product (FFRCT and/ or Plaque Analysis

Other

Please attach your detailed proposal.

Max. file size: 2 GB.

The proposal should include the objectives, study rationale, study design, study population, inclusion/ exclusion criteria, primary and secondary endpoint(s), estimated study duration, # of participants, # of sites and details on the type and amount of support that is being requested. Please include any information on other financial support being used to perform the trial (grant(s), other sponsors or co-sponsors).