Become an Investigator

Fields marked in red with an asterix (*) are required

Details of Investigator

Title *

First Name *

Last Name *

Telephone Number *

Fax Number

Email *

Professional qualifications (e.g. MD, MB, PhD)

Job Title

Institution *

Department/Centre *

Address *

Country *

Primary field of practice *

Other field of practice

Details of Study Centre

Personnel (tick all available)

Epileptologists Adult neurologists Paediatric neurologists Psychiatrists
Neuroradiologists Neuropsychologists Epilepsy nurse specialists Personnel Others (stipulate)

Other Personnel

Facilities (tick all available)

Study Centre provides or has access to

Routine EEG Ambulatory 24 hour EEG Video EEG telemetry
Intracranial EEG monitoring Brain Imaging - CT Brain Imaging - MRI Brain Imaging - SPECT
Brain Imaging - MEG Brain Imaging - PET Drug levels
Epilepsy surgery Facilities Others (stipulate)

Other Facilities

Recruitment feasibility

How many epilepsy patients do you see per month?

- % chronic epilepsy

- % newly diagnosed / newly treated

- % aged 2-15 years

- % aged 16 years or above

Based on the study protocol, how many patients do you estimate you could enrol per year? *

Declaration by investigator

I agree to perform the study procedures as per protocol. *
I confirm that ethical considerations have been fulfilled according to national requirement. *