Create New Account
This portal is intended for researchers proposing and/or collaborating on Investigator Sponsored Research (ISR) to create an account that will allow them to access the ViiV ISR portal.
Please complete the following form. You will not be able to save the form without providing ALL required fields.
(*) indicates required fields.
*
Country* Country Not Selected Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Sint Eustatius & Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island & McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic Of) Isle of Man Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Dem People's Rep Korea, Republic Of Kuwait Kyrgyzstan Lao Peoples Dem Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Kitts And Nevis Saint Lucia Saint Martin (French part) Saint Vincent & The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) S Georgia & The S Sandwich Isl Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Saint Helena, Ascen&T da Cunha Saint Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States U.S. Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Viet Nam British Virgin Islands U.S. Virgin Islands Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe
In selecting a password remember that all passwords must include at least 12 characters. The characters must include and at least 1 of each of the following: number, UPPER case, lower case, and symbol.
Medical / Healthcare Professional Certification
Are you registered to practice and prescribe medicines?
Yes
No
Please list ALL countries in which you are registered to practice. If
you have a license to practice in the US, list ALL State(s) in which you have an active license.
General Conflict of Interest
Do you or a close family member have any actual or perceived position of influence or other actual or
potential
conflict of interest that could affect GSK/ViiV business?
An actual or perceived influence can arise from:
- Being a government official, or having close ties to government officials or government
institutions;
If you are acting solely in your capacity as an HCP/OHS (e.g. prescribing, administering and supplying
medicines or influencing the same, conducting clinical trials or scientific research), then, generally,
you
will not have an actual or perceived influence that may affect GSK /ViiV business.
Yes
No
Identification of COI Areas
Are you a government employee?
Government refers to public international organisations (e.g., the World Health Organisation or United
Nations)
and all levels and subdivisions of governments, i.e. local, regional, national, administrative, legislative,
executive, or judicial, royal or ruling families, state-owned enterprises or any other entities controlled
by the
state.
Please provide details for your response:
Are you an officer or employee of a political party, or a candidate for public office?
Please provide details for your response:
Do you make purchasing decisions that could affect GSK/ViiV business?
Please provide details for your response:
Are you a member of a formulary committee or similar body in relation to government hospitals, other
state-owned
bodies or similar External Business(es)?
External Business refers to private pharmacy or healthcare companies that may have the opportunity to
distribute,
dispense or sell GSK/ViiV medicines or products
Please provide details for your response:
Are you responsible for allocating or influencing expenditures of funds that could affect GSK/ViiV business?
Please provide details for your response:
Are you a member of any boards that could create a conflict of interest with GSK/ViiV?
Note any external boards that may have influence or make recommendations related to the use of GSK/ViiV's
products
and/or business operations
Please provide details for your response:
Do you have a close family member (e.g. spouse, children, parents, siblings) who falls under any of the
previous categories identified above in this section of questions (Identification of COI Areas)?
Please provide details for your response:
Are you a patient or healthy volunteer currently participating in a GSK/ViiV sponsored interventional
clinical
trial?
Please provide details for your response:
All of the answers in this section have been identified as "No", if this is correct, please consider
updating the question in the General Conflict of Interest section, currently answered as Yes, to No.
Request for data privacy consent
If you have responded "Yes" to any of the questions above, by saving and submitting this declaration
i. you consent to GSK/ViiV using information you provide about your response to carry out the
conflict of
interest
check; and
This form may capture sensitive information, such as health or HIV status, or any other sensitive personal
information you may choose to disclose. We will only process this information to assess your actual or
perceived
conflicts of interest. Further information relating to how GSK/ViiV Healthcare will process your personal
information can be found in the
privacy notice .
Consent can be withdrawn at any time. Please see the privacy notice for
further
information.
Verification
Please enter todays date to verify that that all information is correct as of this date.
Ver 20260106
Express Consent Collection Statement
This site will allow you to establish a personalized account for the purpose of interacting with ViiV Healthcare. To create a personalized account, you must provide some personal data, including your name and email address. ViIV Healthcare will use the information you submit to maintain your account, to automatically complete other forms on the Site, and otherwise as described in our Privacy Notice .
By clicking the I AGREE button and/or submitting your request, you acknowledge and agree to the following terms:
You are confirming that you have reviewed the Privacy Notice.
You agree not to submit through this portal any information that identifies or could be used to identify a patient, including the patient’s name or initials, address, date of birth, government-issued identification number, race or ethnicity, gender, or sexual orientation.
You agree not to submit any safety information through this portal. Any safety information, such as adverse event information, will instead be submitted using the hyperlinks or other contact information provided.
You acknowledge that ViiV Healthcare reserves the right to correct any administrative or technology-based errors that may occur during the request or review process.
Please refer to the Privacy notice section, "How to contact us " for direct contact information.
Just a moment, the page is loading...