attachment_1e

Attach_1e_RUF

OMB#0925-0624
Expiration Date: 12/31/2013

Public reporting burden for this collection of information is estimated to vary from 10 to 11minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and
a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974,
Bethesda, MD 20892-7974, ATTN: PRA (OMB#0925-0624). Do not return the completed form to this address.

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OMB#0925-0624
Expiration Date: 12/31/2013

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-IAM go to https:/eapps-ctep.nci.nih.gov/iam.
Cooperative Group Updates:
Investigators added
and associates
added
to the CTSU
institution
must
be active onGroup
a
Investigators
to the CTSU
institution
rosters
must be rosters
active on
a Cooperative
Cooperative
Group
treatment
roster of the institution.
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:________________________________ CTEP ID_______________
Date: __________________________
Internal Use Only

Date Received

Date Processed

Processor

QA