Restart Trial






EXPRESSION OF INTEREST TO COLLABORATE FROM A HOSPITAL IN THE UNITED KINGDOM


  • RESTART is only open to hospitals in the United Kingdom.
  • If, based on our protocol summary, you feel that your hospital may be able to join RESTART, please enter your details and those of your hospital on this form. This information will help us to determine your hospital's suitability for RESTART.
  • Note that all fields on this form are compulsory, except for those marked optional.
  • We will be back in touch with you in due course.



DETAILS OF THE PERSON COMPLETING THIS FORM:
Title, forename and surname:
Job Title:
Email:
Telephone Number:
Please remove spaces and characters

YOUR HOSPITAL:
Hospital's City:
Hospital Name:
If in England, which CLRN? (Optional)
Which Stroke Research Network region?

Stroke Research Network manager contact details:

Name: (Optional)
Email: (Optional)

YOUR HOSPITAL'S EXPERIENCE:
Does your hospital manage inpatients or outpatients with intracerebral haemorrhage (ICH)?
Yes
No

Is there a consultant with an interest in stroke, who has read the protocol summary (HERE) and is willing to fulfil the responsibilities
of a Principal Investigator (PI)?

Yes
No


If yes, please name the consultant who has agreed to act as the PI.

Name: (Optional)
Email: (Optional)
Has the potential PI and local team had previous
experience running a clinical trial of an investigational
medicinal product (CTIMP):

Yes
No


YOUR LOCAL RADIOLOGY FACILITIES:

Note that although MRI is not absolutely required to participate, RESTART aims to obtain MRI prior to randomisation in as many participants as possible (NB MRI can be reimbursed by our budget).

Do you have on-site MRI scanning facilities?
Yes
No

If yes, which are your MRI facilities used for?
(tick all that apply)

Clinical Indications
Research Studies

If no, do you have off-site MRI scanning facilities?

Yes
No


(click to clear response)
If you have MRI facilities on- or off-site, do you know if gradient recalled echo (GRE) T2* sequences can be performed?
Yes
No
Don't Know

Does your Radiology department have experience of participating in multi-centre MRI studies?
Yes
No
Don't Know

Has a consultant radiologist been included in the discussions about the trial and agreed, on behalf of the radiology team, to participate in accordance with the MRI protocol?
Yes
No


If yes, please name the consultant radiologist who will be responsible for RESTART imaging

Name: (Optional)
Email: (Optional)