VA Form 10-0455 Clinical Trial Annual Progress Report

VA Form 10-0455 or the "Clinical Trial Annual Progress Report" is a form issued by the United States Department of Veterans Affairs.

The latest fillable PDF version of the VA 10-0455 was issued on June 1, 2007 and can be downloaded down below or found on the Veterans Affairs Forms website.

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CLINICAL TRIAL ANNUAL
PROGRESS REPORT
CLINICAL SCIENCE RESEARCH & DEVELOPMENT SERVICE
TITLE OF PROJECT
PROJECT ID
REVIEW GROUP
REPORTING PERIOD (MM/DD/YYYY)
PROJECT PERIOD (MM/DD/YYYY)
FROM
FROM
THROUGH
THROUGH
PRINCIPAL INVESTIGATOR
DEGREE(S)
NAME (LAST, FIRST, MI)
ADDRESS
CITY
STATE
ZIP CODE
E-MAIL ADDRESS
TELEPHONE NUMBER
VA MEDICAL CENTER
NAME
SITE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
E-MAIL ADDRESS
ACOS RESEARCH
TELEPHONE NUMBER
HUMAN
RESEARCH
IF EXEMPT EXEMPTION #
IF NOT EXEMPT:IRB APPROVAL DATE
SUBJECTS
EXEMPT
NO
YES
NO
YES
FULL IRB
EXPEDITED REVIEW
BY IRB
BY INDEPENDENT DSMB
DATA SAFETY MONITORING
PREVIOUSLY REPORTED
NO
YES
INVENTIONS AND PATENTS
IF YES
NOT PREVIOUSLY REPORTED
PERFORMANCE SITE(S)
OFFICE
LABORATORY
IF “NON-VA” INCLUDE ADDRESS
LOCATION
LOCATION
ADDRESS
VA
VA
CITY
STATE
ZIP CODE
NON-VA
NON-VA
VA FORM
10-0455
Page 1 of 2
JUNE 2007
CLINICAL TRIAL ANNUAL
PROGRESS REPORT
CLINICAL SCIENCE RESEARCH & DEVELOPMENT SERVICE
TITLE OF PROJECT
PROJECT ID
REVIEW GROUP
REPORTING PERIOD (MM/DD/YYYY)
PROJECT PERIOD (MM/DD/YYYY)
FROM
FROM
THROUGH
THROUGH
PRINCIPAL INVESTIGATOR
DEGREE(S)
NAME (LAST, FIRST, MI)
ADDRESS
CITY
STATE
ZIP CODE
E-MAIL ADDRESS
TELEPHONE NUMBER
VA MEDICAL CENTER
NAME
SITE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
E-MAIL ADDRESS
ACOS RESEARCH
TELEPHONE NUMBER
HUMAN
RESEARCH
IF EXEMPT EXEMPTION #
IF NOT EXEMPT:IRB APPROVAL DATE
SUBJECTS
EXEMPT
NO
YES
NO
YES
FULL IRB
EXPEDITED REVIEW
BY IRB
BY INDEPENDENT DSMB
DATA SAFETY MONITORING
PREVIOUSLY REPORTED
NO
YES
INVENTIONS AND PATENTS
IF YES
NOT PREVIOUSLY REPORTED
PERFORMANCE SITE(S)
OFFICE
LABORATORY
IF “NON-VA” INCLUDE ADDRESS
LOCATION
LOCATION
ADDRESS
VA
VA
CITY
STATE
ZIP CODE
NON-VA
NON-VA
VA FORM
10-0455
Page 1 of 2
JUNE 2007
PERIOD COVERED BY THIS REPORT
PROJECT ID
PROGRESS REPORT
FROM
SUMMARY
THROUGH
VA MEDICAL CENTER
PRINCIPAL INVESTIGATOR
TITLE OF PROJECT
SUMMARY OF PROGRESS (LIMITED TO 500 WORDS) AND MAJOR FINDINGS, IF AVAILABLE. DESCRIBE ANY RECRUITMENT
DIFFICULTIES AND WHAT IS BEING DONE TO ADDRESS THEM. STATE DATE OF MOST RECENT IRB AND/OR DSMB
MEETING AND COMMITTEE RECOMMENDATIONS.
INDICATE THE NUMBER OF RELATED PUBLICATIONS RESULTING DURING THIS PERIOD:
SUBMITTED
ACCEPTED
IN PRESS
PROVIDE PRIMARY OUTCOME PUBLICATION CITATION; IF AVAILABLE, PLEASE ATTACH A COPY.      
ATTACHMENTS:
ATTACHMENTS:
IRB AND/OR DSMB MINUTES (MOST RECENT) - ATTACH AS A SEPARATE FILE.
PRIMARY OUTCOME PAPER - ATTACH AS A SEPARATE FILE IF AVAILABLE.
If the e-mail button does not work you can send the form to :
Submit by E-mail
VA FORM
10-0455
CLIN-Review@va.gov.
Page 2 of 2
JUNE 2007

Download VA Form 10-0455 Clinical Trial Annual Progress Report

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