REGIONAL CENTER SELECTION QUESTIONNAIRE:

Ancillary Study Title: _____________________________________________________

PIs:___________________________________________________________________

Regional Center Director:__________________________________________________


Please circle (or highlight in bold) the appropriate answers:

1) Is your Regional Center interested in participating in this ancillary study?

YES       NO

2) If yes, does your Regional Center have prior pertinent experience in the area of research of the ancillary study?

YES       NO

3) If yes, please explain:

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Signature of the Regional Center Director

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Date____________________