Form 5 Roster Update

Attachment_A05_ruf
Attach_1e_RUF

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

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including
reporting
burden
for this collection
information
estimated
to varyand
from
10 to 11minutes
perneeded,
response,
thePublic
time for
reviewing
instructions,
searchingofexisting
data is
sources,
gathering
maintaining
the data
and
including the
for reviewing
instructions,
searchingAn
existing
gathering
and maintaining
the isdata
completing
andtime
reviewing
the collection
of information.
agencydata
maysources,
not conduct
or sponsor,
and a person
not
needed,toand
completing
and reviewing
the collection
of information.
agencyvalid
mayOMB
not conduct
or sponsor,
required
respond
to, a collection
of information
unless
it displays aAn
currently
control number.
Sendand
a personregarding
is not required
to respond
to,oraany
collection
of information
unlessofit information,
displays a currently
OMB
comments
this burden
estimate
other aspect
of this collection
includingvalid
suggestions
forcontrol
reducing
this burden,
NIH, Project
Clearance
Branch,
6705 Rockledge
Drive,
MSCof7974,
Bethesda,ofMD
number.
Send to:
comments
regarding
this burden
estimate
or any other
aspect
this collection
information,
20892-7974,
ATTN: PRA for
(OMB#0925-xxxx).
Do not
the completed
form
to this
address.
including suggestions
reducing this burden,
to:return
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.

Filling out PDF Forms
This PDF form contains “roll-over or double-click ” help functionality.
This form allows you to enter data directly onto the screen. After completing the form,
you are able to print the document so that you can fax/mail the document.

To fill out a form:
1. Select the hand tool.
2. Position the pointer inside a field, and click to type text.
3. After entering text or selecting a check box, do one of the following:
- Press tab to accept the form field change and go to the next form field.
- Press Shift+Tab to accept the form field change and go to the previous form
field.
- Press Enter (Windows) or Return (Mac OS) to accept the form field change and
deselect the current form field.
4. Once completed, print the form.

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

Attachment_A5_ruf
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 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:________________________________ CTEP ID_______________
Date: __________________________
Internal Use Only

Date Received

Final_October_2016
Authorized by CTSU for local reproduction

Date Processed

Processor

QA