Become A Clinical Trial Volunteer

If you would like to be contacted about future clinical trials please read the Information Sheet (click here)

Registration of Interest Form

First Name:

Last Name:

Sex:

Date Of Birth:

(e.g. 21/1/1970) *

Ethnicity:

NHI Number (if known):

Email:

Address

Building:

Street/PO Box:

Suburb:

Town/City:

Postcode:

Country:

New Zealand

Phone Numbers

Home:

Work:

* Ext.

Mobile:

Clinical Trials Previously Participated in:

Have you ever participated in a clinical trial?

Yes No

If Yes, please provide the details below.
(You can drag the following trials to the empty box below. Hold the Ctrl key to select multiple trials.)

CCRep trials that you may have participated in:

ADVANCE: Action in Diabetes and Vascular Disease
Appraise
Aradigm Bronchiectasis
Aralast BAL
Aspire
ATLAS
balANZ
Bariatric Surgery Study
Bayhill Phase 1 Study
BI 1218.43
BI 1218.64
BI 352:2046
BI Diabetes Extension Study
CANVAS
CAPES - Cognitive Assessment Post Elective Surgery
CAPTIVATE
CBio Study
Celgene CLL
Centocor Golimumab Study
Cephalon NHL
Champion
CoDa Ascend
DAL- Outcomes (NC20971)
DAPT
DIA3010
DiObex Diabetes Study
Early Parenteral Nutrition
Einstein VTE Study
EISAI GERD Study
EMBRACE - Prophylactic Azithromycin for Bronchiectasis
Emerge 2
Emerge 5
Emerge 6
Engage
EVOLVE
EXCELLA II
EXTEND
FILM Study
Gilead Hep B (-) Study
Gilead Hep B (+) Study
Golimumab II
Gout HRC
HOKUSAI
IMPROVE-IT
INEOS
LABA - BI 1222.11
Lilly ICU Study
MabThera Retreatment Study
MAGELLAN Study
Mannitol
Mannitol III
MEDAL
MK 0431 C
Novartis Hepatitis B
Numax RSV Study
Obesity 2 Study - extension
ONTARGET/TRANSCEND
OPTIMA
PERFORM
Pfizer CP-690
Pharmasset - Hep B Study
Pharmasset + Hep B Study
Pioglitazone Diabetes Study
Platinum QCA
Platinum WH
PPD Open-Label Extension Study
Psoriatic Arthritis
RECORD
Recover
Recover II 1160.46
Remedy
Revlite
SHARP: The Study of Heart and Renal Protection
SOLID TIMI 52
STABILITY
STATINS Study
Summacta (WA22762)
T16 - Ulcerative Collitus Study
T18 - Ulcerative Collitis Study
Takeda 305
Takeda 402 (SYR-322_402)
TECOS
Tenofovir versus Adefovir for the Treatment of HBeAg negative Chronic Hepatitis B
Tenofovir versus Adefovir for the Treatment of HBeAG positive Chronic Hepatitis B.
TIDEL II Study
TRA2P Study
TRACER Study
uRNA
VANTAGE Multiple Myeloma
Watch and Wait
Xenotransplantation

Type the trial names, and/or 'drag and drop' from the above list.

Checklist of Health Conditions

Do you have any existing Health Conditions:

Yes No

I have read the Information Sheet about the Clinical Trial Participant Database. Any questions I have about the database have been satisfactorily answered by a CCRep staff member.

I understand that my information will be securely stored in a database of prospective clinical trial participants held by the Centre for Clinical Research and effective practice (CCRep), and will be accessed only by authorised CCRep staff. I understand that providing my information and allowing it to be stored on the database is completely voluntary.

I also understand that my information will be stored for the sole purpose of facilitating CCRep in notifying me about future trials I may be able to participate in. I understand that there is no obligation for me to be involved in any trial and that I can have my information removed at any time. I am also aware that I can access my information and/or have it corrected.

I understand that if I wish to have my information removed I will need to contact the Database Administrator with my request.

I have read the above conditions.

Top of Page

Clinical trials are important

Clinical trials answer important scientific questions and suggest future research directions. Because of progress made through clinical trials, many people are now living longer. In order to conduct clinical trials more efficiently and to enhance the value of research activities at CMDHB we have created a Clinical Trial Participant Database.

The database stores simple information including contact details, gender, date of birth, and health conditions. Becoming a clinical trial volunteer is completely your choice.

Currently over 750 participants are enrolled in clinical trials at CCRep.

Clinical Trial Information | Register as a Volunteer | Research Facilities

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