Application Form

This online application form should take no more than ten minutes to complete and will enable us to establish your suitability for a study. Please answer the questions as honestly as possible to enable us to make a quick decision.

Only fill in this on-line application if you haven't contacted ICON Volunteer Recruitment before to request an application pack. For any queries relating to registered Volunteers please e-mail volunteers.man@iconplc.com.

Are you a suitable volunteer?

Before you can take part in a study, we’ll need your GP to complete a questionnaire about your medical history, for which we’ll ask your permission. This is so we can be absolutely sure you are in good health to take part in one of our studies. If you have any doubts about your suitability, please call our recruitment staff who will be able to help and advise you. Call the Volunteer Recruitment Team on 0800 328 8000.

Fields market with an * symbol are mandatory.

Volunteering 1-2-3

Answers to all your questions about volunteering.

Title
Forename *
Middle Name
Surname *
Address *

Town *
Region
Postcode *
Country *
Nationality *

Email *
Phone
Mobile
Where did you hear about ICON?
Gender *	Male Female
Ethnic Origin *
If Other, please specify
Is English your first language? *	Yes No
Date of Birth (dd/mm/yyyy) *
Age
Height/Weight *

BMI
Employment Status
Are you currently taking any medication? *	Yes No
If yes please give details
Have you ever suffered from any of the following?
Osteo Arthritis
Rheumatoid Arthritis
Depression / Attempted Suicide
Epilepsy
Thyroid problems
Stroke
Heart attack including Angina
Glaucoma
Visual Problems
Hepatitis including liver problems
Renal Problems
Any type of cancer
Diabetes
High or Low Blood Pressure
Stomach Problems
Coeliac Disease
Colitis
Irritable Bowel Syndrome
Neurological problems
Deafness
Skin problems
Surgical history
Allergies
Special Dietary Requirements
Asthma / Wheeze

Was it diagnosed by a doctor? *	Yes No
Have you ever been admitted to hospital due to your asthma/wheeze? *	Yes No
Have you suffered from an asthma/wheeze attack since the age of 16? *	Yes No
When did you last have an asthma/wheeze attack? *
Have you ever used an inhaler or taken tablets for your asthma / wheeze? *	Yes No
If Yes, please state the name of the inhaler and tablets used along with the date last used
Do you use a bronchodilator on a regular basis? *	Yes No
If Yes, please state the name of the bronchodilator and frequency of useage
Have you ever been prescribed inhaled or oral steroids for your asthma/wheeze? *	Yes No

Other Respiratory Problems
What is your primary reason for wanting to be a volunteer?
What could influence you the most when choosing a study to take part in?
Do you have a preference of the time of year you take part in a study?
How much notice do you require prior to taking part in a study?
Please indicate if you would prefer not to take part in a study that requires the study drug to be given in the following ways:	Oral (mouth): IV (drip): Injection: Creams: Inhaler: No preference:
Social Drug Use
If you use social drugs please tick the relevant box(es), frequency and date last used:
Cocaine
Heroin
Amphetamine
Cannabis
Do you smoke? *	Yes No
If yes how many cigarettes/cigars per day?
If yes which brand of cigarette/cigar do you smoke?
Do you drink alcohol? *	Yes No
If yes how many units do you drink in a week?
Given that 1 pint of beer/lager is 2 units and 1 glass of wine or 1 measure of spirit is 1 unit.

Are you a suitable volunteer?

Social Drug Use

For males only

For females only

GP Information

For males only
Do you have a regular female partner? *	Yes No
If yes, what type of hormonal contraception does your partner use?
If your partner is taking the Pill please state the name.
Have you had a vasectomy? *	Yes No
If so what year?

For females only
Do you have a child under the age of 12 months? *	Yes No
Are you currently breastfeeding? *	Yes No
What type of hormonal contraception do you use?
If you are taking the Pill please state the brand and how long you have been taking it *
If you have been surgically sterilised please note the date of the operation *
If you have had a hysterectomy please note the date of the operation *
Have you been through the menopause? *	Yes No
Are you using HRT? *	Yes No
If so which treatment?
When did you last have a smear test? *
If applicable what was the result of your smear test? *

GP Information
Are you currently registered with a GP in the UK who holds at least 3 years of your medical history? *	Yes No
GP Name *
GP Address *
GP Town *
GP Postcode *
GP Phone number
GP Fax


I have read and agreed to the ICON Development Solutions Data Protection Policy *

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