Clinical trial identifiers
Trial title:
Short name:
Protocol no.
Description of the trial
Question, hypotheses, objective, endpoints, etc.:
Study design:	single-centre	multi-centre
open-label	single-blind	double-blind
randomised	cross-over
verum-controlled	placebo-controlled
Investigator initiated	not Investigator initiated
other:
Phase:	I	II	III	IV	Other (e.g. Ib, IIa):
Total number of subjects/patients:	of which at USZ:
Trial start:
Planned trial duration:
Schedule detailed at USZ:
Parties involved:
Sponsor: (Company/Contact person/Tel/Fax/E-mail)
CRO: (Company/Name Clinical Research Associate (CRA)/Tel/Fax/E-mail)
Principal Investigator (PI): (Clinic/Name/Tel/Fax/E-mail)
Pflegepersonal / Study Nurse: (Clinic/Name/Tel/Fax/E-mail)
Authorities and approvals:
Cantonal Ethics Committee (CEC):	Application pending, expected submission date:
Application submitted on:
Positive CEC approval received on:
CEC number:
Swissmedic notification:	Application pending, expected submission date:
Application submitted on:
Swissmedic notification received on:
Swissmedic notification number:
other (e.g. BAG):
Tasks for the Cantonal Pharmacy:
product development
sterile manufacturing	non-sterile manufacturing	no manufacturing
packaging
creating the randomisation list/s
use of computerized systems (IVRS, IWRS, IRT, IXRS)
blinding of the IMP in accordance with the randomisation list / IVRS
storage	disposal	accounting
other:
Order to the Cantonal Pharmacy: (Please specify precisely the nature and scope of the order. Please discuss with the responsible person at the KAZ.)

Payment	KAZ costumer number (debtor):
Pay office	USZ	Profitzenter:
UZH	PSE Element:
Others:
Invoice recipient:
Client / Company
Name:
Department:
Street / No.:
Post code / Town/City / Country
IC no. (Zurich canton intercompany no.)
Remarks: Payment deadline:	days
Invoice address: (if different to invoice recipient)
Client / Company
Street / No.:
Post code / Town/City / Country

Application completed by
Place:	Date:	Sponsor’s signature
CRA’s signature
PI’s signature

Responsible person at the Cantonal Pharmacy:	Study Coordination Kantonsapotheke Zürich Südstrasse 3 8952 Schlieren Tel: +41 (0)43 258 54 12 Email: Studien@kaz.zh.ch

Please return this application once completed and signed, along with the draft trial protocol, to the Study Coordination of the Cantonal Pharmacy.

The application will be evaluated by the KAZ and an offer created. The work order to the Cantonal Pharmacy must follow in writing.