Form 5 Attach 1E - CTSU Roster Update Form

attach_1e_RUF

OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

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201010v.5

OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

attach_1e_RUF

CTSU ROSTER UPDATE FORM
Please note that all persons added to the CTSU site rosters must have an active status with the NCI.
Investigators must register annually with the Pharmaceutical Management Branch and associates must
maintain an active CTEP-IAM account. To link to the CTEP-AMS go to https:/eappsctep.nci.nih.gov/iam.

Cooperative Group Updates:
• Investigators added to the CTSU institution rosters must be active on a Cooperative Group
treatment roster of the institution.
• Roles may be assigned to the person by the Site Administrator or Site Data Administrator via the
CTSU members’ web site at https://members.ctsu.org under the Regulatory tab.
Add or Delete persons to site roster: (attach a listing if required)
Site Name
Institution Code
CTEP Person ID
Person Name

Add
Person

Delete
Person

Update or Delete the CTSU Administrator and/or Data Administrator role at an institution: (Only
1 person may hold either the Site Admin or Data Admin role at an institution.)
Site Name
Institution
CTEP
Person Name
Role (Admin Add
Delete Delete
Code
Person
or DA)
Role
Role
Role &
ID
Only
Roster
Record

Person accepting the role of Site Administrator must sign the statement below:
I understand that all general correspondence for CTSU related activities will be directed to my
attention and it is my responsibility to forward such correspondence to the appropriate physician
and staff members at my institution. It is also my responsibility to assign staff roles and to access
restricted areas of the CTSU web site as required.
Signature: ___________________________

Date: _________________

Persons accepting the role of Site Data Administrator must sign the statement below:
I understand that all CTSU general data management correspondence will be directed to my
attention. I may assign data management responsibilities for individual protocols or organizations
to data management staff at my institution, but it is my responsibility to keep the names of these
individuals current via the roster maintenance screens on the CTSU web site.
Signature: __________________________

Date: ___________________

Please return the completed form to the CTSU Membership Coordinator at fax 1-888-691-8039.
Person submitting form:____________________

Date: __________________________

Internal Use Only

Processor

201010v.5

Date Received

Date Processed

QA

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