ULYSSES Study Protocol DSC/14/2357/50 Subject Travel Portal

For Subject travel or reimbursement, you will be required to submit initial information via this Travel Portal.

Please Note: Submissions are received and processed during business hours. If a submission is recieved after hours or on a weekend it will be processed the following business day.
Subject Travel Portal

ULYSSES Study Protocol DSC/14/2357/50
The information collected on this website is used solely for travel and hotel logistics purposes. Information will not be shared for any other purpose.
Travel Portal
Site Number
Subject Number
Coordinator Name
Coordinator Email
example@example.com
PI Name
Site Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Submission option
Subject Information
Is Subject 18 Years of age or older?
Guardian Name
Name of Guardian Traveling with Subject
Guardian / Relationship
Guardian Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent or Legal Guardian Phone Number
Guardian Email Address
example@example.com
Subjects Name
Please enter entire legal name
Subject Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Subjects Email Address
example@example.com
Subject Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Subject Phone Number
Is the Subject able to communicate in English? (Y/N)
What is the preferred language of communication for Subject?
Travel
Subject Number
How will Subject travel to your site
Please confirm the wheelchair type
Foldable, Electric-Motorized ...
Visit Name
How many caregivers will travel with the subject
Please list Date of Birth of travelling Caregiver(s) and Disability Card Number if available as well as other notes.
Patient Pick-up Address
For example: Pick-up Address Subject special seating request, travel time of day, or any restrictions
Visit Name
Name as it appears on account (EU & Canada)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
IBAN Account Number (EU Only)
Must Enter to Receive Reimbursement (EU Only)
SWIFT Code
Account Number (Canada Only)
Routing Number (Canada Only)
How many people traveled to this visit
Additional notes and comments
Browse Files to Upload

Browse Files
Use Browse Files to Upload Any Documents Cancelof
Privacy Policy

Subject Travel Portal

Travel Portal

Subject Information

Travel