Study Volunteer Database

PPD is now offering U.S. residents the opportunity to add their names and brief profiles to a database of potential research study volunteers.

By registering your name and profile in our research study volunteer database, you will be automatically considered and notified when PPD has a research study matching your profile.

This form is for potential study volunteers with pre-existing conditions in the United States only.

Please provide the following information.

(Fields marked with * are required)

Study volunteer's first name: *

Study volunteer's last name: *

Address 1:

Address 2:

City:

State:

Zip code:

Daytime phone number: *

Evening phone number:

Contact preference:

Daytime Evening Either E-mail

E-mail address: *

Date of birth:

Gender:

Female Male

Patient conditions:

Please check all that apply

Acne	HIV
Asthma	Hodgkin's
Alzheimer's disease	Hypertension
Attention deficit disorder	Insomnia
Attention deficit hyperactivity disorder	Irritable bowel syndrome (IBS)
Bipolar disorder	Kidney disease
Breast cancer	Low libido
Colon cancer	Lupus
Crohn's disease	Migraines
Chronic obstructive pulmonary disorder (COPD)	Multiple sclerosis
Dementia	Muscular dystrophy
Depression	Non-Hodgkin's lymphoma
Dermatitis	Obesity
Diabetes (type I)	Osteoarthritis
Diabetes (type II)	Osteoporosis
Dry eyes	PMS (premenstrual syndrome)
Eczema	Post-traumatic stress disorder
Epilepsy	Premature ejaculation
Erectile dysfunction	Prostate cancer
GERD (Gastroesophageal reflux disorder)	Psoriasis
H. pylori	Rheumatoid arthritis
Hay fever	Seasonal allergic rhinitis
Heartburn	Schizoaffective disorder
Heart disease	Schizophrenia
Hepatitis type A	Shingles
Hepatitis type B	Skin cancer
Hepatitis type C	Ulcerative colitis
Herpes	Urinary incontinence
High blood pressure	Vaccine research
Other conditions:

Additional information:

Are you the study volunteer submitting information about yourself, or are you the legal guardian for someone unable to submit his or her own information?

Study volunteer
Legal guardian

PPD will retain your contact information which identifies you as a potential volunteer and enables us to contact you in the future. Please be assured that we have taken measures to protect your privacy and confidentiality. The personal information that you provide on our Web site (e.g., name and address), demographic information (e.g., your age and gender) and patient information will be stored in a secure environment and protected by a password known only to PPD. Additional information will not be collected until you have consented to be screened and qualified for enrollment in a study. PPD will not enroll you into a study until you have read and agreed to an informed consent. If you change your mind and want to withdraw your name from PPD’s list of potential volunteers, you may do so at any time.