Clinical Trial Information Submission Form

Name:
E-mail Address:
Date of Submission:
Study Title:
Description of the Clinical Trial:
Purpose:
Description of How Participants' Interests Will Be Protected:
Potential Conflicts of Interest:
Contact Information for All Investigators (please identify the investigator to act as the lead contact):
Web site or E-mail Address for Additional Information:
Timeframe for Posting and Withdrawl from the NASS Web site:
*Anticipated Submission of Study Results to SpineLine:*

Please note that the information provided above will be posted as the background information that
accompanies the posting of clinical trial information on the NASS Web site. In addition to this
information submission form, you must complete and sign the Terms of Agreement (accessible on the
NASS Research Opportunities Web page).