Last Mod:
on:
Anonymous
12/13/2018 10:57:17 PM
©ResearchPoint Global 2018

ResearchPoint Global complies with the U.S.-EU & U.S.-Swiss Safe Harbor Frameworks regarding the collection, use, and retention of information voluntarily provided for a specified or implied purpose.

The information collected via this web portal will be used solely for the purpose of matching qualifications and experience with the specific requirements of projects.

If you or your company would like to be removed from this system, please send an email containing 1.) Your Name and Position with your company, 2.) The name/entity to be removed, and 3.) The website or system in which the information was entered or is being used.
Send the email to privacy@researchpoint.com.

We will remove your information from our system within 48 business hours of receipt of your e mail, and return an email to you confirming the information has been removed.

Business Information
Salutation:
First Name:
Last Name:
Title:
Company:
Address:
City:
State:
Zip:
Country:
Phone: -
Fax: -
Coding Information
Primary Specialty:
- Please list other areas of interest/expertise in the Comments section at the bottom of this form.
Home Page:
E-Mail:
Beeper: -
Moblie Phone: -
Company Tax ID:
Pers Tax ID:
Demographic Information
Age Ranges
    What percentage of your patient population falls into each of the following age ranges?
Please make sure the total equals 100%
Under 18 years
18 - 44 years
45-65 years
Over 65 years



Ethnicity
    What percentage of your patient population falls into each of the following ethnicities?
Please make sure the total equals 100%
Caucasian
Black
Hispanic
Other



Gender Percentages
    What percentage of your patient population falls into each of the following genders?
Please make sure the total equals 100%
Male
Female

Third Party Insurance Coverage
    What percentage of your patient population is covered by Medicaid?
    What percentage of your patient population is covered by private insurance?

Person Completing this Form
Full Name:
Address:
City:
State:
Zip:
Country:
Phone:
Fax:

Comments and Followup Plan

Please review all information prior to Submission. This system doesn't include editing.