Investigator Contact Form

All new/existing investigators are asked to fill out this form to obtain a username & password to the new bvari.org. Please fill out the form as completely as possible, keeping in mind that fields marked with a * are required.

If you have any questions, please feel free to contact Dan Burke at, dan.burke@bvari.org.

Please enter the requested information:
*Investigator Name:

Academic Affiliate: Boston University - School of Medicine
Harvard Medical School
None
Other:

*Primary VA Campus: Brockton Jamaica Plain West Roxbury
*Medical Department(If none, insert None):
*Medical Division (If none, insert None):

Office Address/Contact Information:
*Address 1:
Address 2:
*City:   *State:   *Postal Code:
*Telephone Number:
Pager/Mobile Number:
Fax Number:
*Email:

Primary Administrators Information:
Name:
Phone Number:
Fax Number:
Email:

All Correspondence & Financial Info to:
Same as Office Address
Address 1:
Address 2:
City:   State:   Postal Code: