CSORN Site Enrollment Form

Your name *

Email address *

Site Name

Principal Investigator *

CO-PIs *

Approximate # of spine surgeries per year

Do you have a research team? *
YesNo

If yes, how many coordinators do you have on staff?

Are these coordinators full-time or part-time?
Full-timePart-time

Please list the coordinator(s) name and contact information

If not, we strongly recommend that you have a minimum of one staff member in place (part-time or full-time) before you join CSORN.

How are your research coordinator (s) funded

For how long are your research coordinator (s) funded?

If you lose your research coordinator, do you have a plan to capture CSORN follow-ups and/or data that is due?

YesNo

If follow-ups are not within the 10% national average you will be placed on probation and possibly removed from CSORN). Please indicate details of the plan

To join CSORN, the minimum number of enrolments is 20 cases per year. Less than 20 enrolments may result in your site being placed on probation and possibly removed from CSORN. Do you agree?

YesNo

As a surgeon participating, you will have to complete numerous clinical/surgeon forms for CSORN: Initial Clinical Assessment Form, Surgical Procedure Form, Discharge Form, and Adverse Event forms. Do you agree to complete these required forms?

YesNo