Clinical Trial Advertisement Request
1. HIC #
2. Primary Investigator UVa Mail ID: (ex. srh@virginia.edu)
3. Study Contact UVa Mail ID: (ex. srh@virginia.edu)
To obtain UVa Mail IDs search the people directory.
4. Where will this ad be used?
Please select from the following media types:
[optional information]
Media type: Ad is in final form:
Public Service Announcement by Adelphia Cable yes no
Television  yes no
Poster/Flyers yes no
Newspaper/Journal Ads yes no
Radio yes no
(By default your trial advertisement will appear on the Health System Clinical Trials web site.)
5. Include the trial in the selected
medical area categorical listings:
(maximum of 2) 		 (Hold down Ctrl Key for multiple selections)
 
6. Choose keywords:
(maximum of 3)		 (Hold down Ctrl Key for multiple selections)
 
6a. Request a new keyword
      not listed above
[optional information]

(Note: suggesting a keyword addition to the approved keyword list will be not guarantee it's usage in your ad, but will be considered by the HIC office. A selection from the approved list is required.)
7. Please provide a lay person headline for your trial: (max 100 characters)
(example: Women 25 - 50 with PCOS wanted for hormone study)
8. Attach advertisement documents:
(a web ad is required for all trials)
 (web ad)
(other ad)
(other ad)
(other ad)
8a. Use my existing clinical trial title as my web site advertisement.
8b. I have a non-electronic document web advertisement to submit.
8c. I have already submitted a web advertisement for this trial.

Note:A web advertisement submission is required for all advertised clinical trials.
Information about the person designated to receive the approval notice:
9a. Full Name:
9b. Phone Number:      9c. Email:
9d. Messenger Mail Box: