C-TRACT Study Site Questionnaire C-Tract Study Site Questionnaire KEY PERSONNEL CONTACT INFORMATION Name of Site Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Primary Contact Person First and Last Name Email Address Phone Number Site Principal Investigator (PI) Email Address Phone Number PI Subspecialty FACILITY INFORMATION Please list the Primary Hospital at which you plan to enroll patients, as well as up to two major affiliate hospital that fall within your IRB’s jurisdiction. Primary Hospital Estimated yearly number of DVT Cases (irrespective of treatment type) Estimated yearly number of patients with moderate-severe PTS (any treatment type) Affiliate Hospital #1 Which category best describes the nature of your Primary Hospital? University Hospital Community Hospital with Strong Academic Affiliation Private Hospital without Strong Academic Affiliation OtherOther Which of the following categories best describes the nature of Affiliate Hospital #1? University Hospital Community Hospital with Strong Academic Affiliation Private Hospital without Strong Academic Affiliation Affiliate Hospital #2 Which of the following categories best describes the nature of Affiliate Hospital #2 University Hospital Community Hospital with Strong Academic Affiliation Private Hospital without Strong Academic Affilation Wound or Ulcer Care Clinic Yearly number of patients seen RESEARCH COORDINATOR INFORMATION Research Coordinator First and Last Name Email Address Phone Number Number of Years Research Experience ENDOVASCULAR THERAPY (EVT) Primary Endovascular Co-Investigator (will oversee EVT) First and Last Name Email Address Phone Number Subspecialty Number of years since completion of training How many iliac vein stent procedures are performed in the group yearly? How many are for treatment of chronic DVT with moderate-severe PTS? What stent do you prefer? MEDICAL AND COMPRESSIVE PTS THERAPY Primary Medical Co-Investigator (will oversee standard PTS care) First and Last Name Email Address Phone Number Subspecialty Number of years since completion of training VENOUS ULCER CARE Primary Ulcer Care Co-Investigator (will oversee venous ulcer care) First and Last Name Email Address Phone Number Subspecialty Number of years since completion of training How many venous ulcers has this investigator managed? SITE-SPECIFIC ENROLLMENT AND DATA COLLECTION Is your research team willing to engage in an active ongoing quality improvement program with study leadership to maximize the potential for enrollment? Yes No Have you or your institution utilized electronic (e.g. EHR-based or electronic queries of other databases) methods of identifying patients for clinical research? Yes No If yes, please specify Vascular Ultrasound capabilities: Is your ultrasound lab willing to identify patients for the C-TRACT study? Yes No Is your ultrasound lab willing to complete web-based training to become qualified to submit ultrasound exams for study patients to a core lab? Yes No Venogram Imaging capabilities: Is your angiography lab willing and able to transfer pre- and post-procedure venograms to a core lab using a DICOM-compatible interface? Yes No COMPETITIVE ENROLLMENT Please name any studies at your site that expect to enroll patients with DVT or PTS from 2017-2020, and indicate how problems with competitive enrollment will be avoided. STATEMENT OF CLINICAL EQUIPOISE Does each co-investigator accept the premise that it is ethical and appropriate to randomize patients with moderate-severe PTS (including patients with venous ulcers less than 6 cm) to receive either EVT or no EVT in a trial (along with medical therapy, compression, and venous ulcer care as needed), and maintain them in their assigned treatment arm for 6-18 months (with rare exceptions)? YES No Maybe If the answer to this question is anything but an unequivocal YES, please explain Email This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Submit