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Add or Update Information on Clinic

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Name of Clinic:

Address:

Phone Number:

Include toll-free

In-Patient Capacity:

Website address:

Does this clinic list current studies on its website?

	Yes
	Yes, but rarely up to date
	No
	Not Sure

How is the screening process?

Include phone and in-clinic. One visit? Fast? Slow? Group screenings? Any other thoughts?

Volunteer Ameniies:

Check all that apply

	Big Screen TV
	In Room TV
	Private Bedside TV
	Cable
	Satellite
	DVD Player
	Video Games
	Board Games
	Pool Table
	Ping Pong
	Foos Ball
	Darts
	Movie Library
	Quiet Room
	Computer Room
	Rec Room
	TV Room
	Activities like crafts, bingo or tournaments

Internet Access:

Check all that apply

	Wifi
	LAN
	Public Computers w/ Internet
	Public Compuers w/o Internet

Housing:

Check all that apply

	Private rooms
	Semi-Private (less than 4)
	Dorms (more than 5)
	Hospital Beds
	Beds

Climate:

	Brrrr! Bring a hoodie and blanket!
	A little on the chilly side
	Comfortable for most people
	A little on the stuffy side
	Hot and dry! Bring your speedo!

Parking:

Check all that apply

	Ample Parking
	Limited Parking (Make sure you park in the proper place)
	Off-property lot
	Surveillance/Security
	Few instances of break-ins
	Lots of break-ins. PARK AT YOUR OWN RISK!

Food Service:

	Prepared in-house
	Catered
	Provided by hospital
	Who knows

Payment:

How is the payment process? Fast? Slow? Checks? Debit cards? Bank drawn on?

Camera Policy:

Can you bring camera phones, laptops with webcams?

	Allowed
	Not Allowed
	Not Sure

Clothing:

Check all that apply

	Tops and bottoms provided
	Tops provided
	Bring enough clothes for length of study
	Laundry done for longer studies
	Self Laundry facilties
	No Laundry

Local bus and transit info:

Bus line to get to or near clinic. Cost. Company.

Any additional information you wish to provide about this clinic?