Application Form for Associate Membership
Application form for associate membership – version date: 1404151
Application form for associate membership
Date of submission:
Please note: since this application will be subject to internal review, the application form and preferably all accompanying documents must be completed in English.
1. Basic data
Name of institution /organisation
Contact Person
Surname, first name
Academic degree
Position
Address, No.
ZIP, City
Direct line
Office line
Fax
Host Institution
(if applicable) / (institution which will host the CTU and may provide necessary support)
Name of Institution
Address, No.
ZIP, City
Office line
Fax
Advising full member
(if applicable) / (institution which advises the applicant and will provide necessary support)
Name of Institution
Address, No.
ZIP, City
Office line
Fax
Contributing Authors
(if applicable) / (other persons beside the designated Contact Person who contributed substantially to the conceptual work and/or writing of the application)
Surname, First Name
Institute/Department
Type of Contribution
Surname, First Name
Institute/Department
Type of Contribution
Confirmation by Contact Person
I hereby confirm that all the details given in this proposal, including the appendices, are correct. They were elaborated jointly with all co-authors, the host institution and the advising full member of the SCTO.
Place, date: / Signature:Please include the following documents with the application (where appropriate):
letter of recommendation from the Director of the host institution
other (please specify)
2. Organisation
2.1 Organisational Structure, Organigram, and Overview of Functions and Competences
- Please provide an organigram of your Institution/Organisation.
- Please specify how the necessary competence in clinical study design, trial management, epidemiology, pharmacology, biostatistics, databank design and handling, nursing, and other disciplines to be covered is reached.
- Please provide a short job description for each function listed on the organigram of your CTU. Where appropriate, indicate names and professional background of position holders.
- Please specify, whether are interested to collaborate with a CTU from the CTU network and if yes, in which field(s)
Institution/Organisation Personnel
Function# of Full Time Equivalents
Job Description / Head/Coordinator of Institution/Organisation
%
existing position position not existing
position planned to be established
Function
# of Full Time Equivalents
Job Description / Biostatistician
%
existing position position not existing
position planned to be established interested to collaborate with CTU
Function
# of Full Time Equivalents
Job Description / Secretary / Clinical Trial Administrator
%
existing position position not existing
position planned to be established
Function
# of Full Time Equivalents
Job Description / Quality Manager
%
existing position position not existing
position planned to be established interested to collaborate with CTU
Function
# of Full Time Equivalents
Job Description / Study Manager/Monitor
%
existing position position not existing
position planned to be established interested to collaborate with CTU
Function
# of Full Time Equivalents
Job Description / Study Nurse
%
existing position position not existing
position planned to be established
Function
# of Full Time Equivalents
Job Description / Data Manager
%
existing position position not existing
position planned to be established interested to collaborate with CTU
Function
# of Full Time Equivalents
Job Description / Clinical Epidemiologist
%
existing position position not existing
position planned to be established interested to collaborate with CTU
Function
# of Full Time Equivalents
Job Description / Clinical Pharmacologist
%
existing position position not existing
position planned to be established interested to collaborate with CTU
Add other functions as needed
Function# of Full Time Equivalents
Job Description / Please specify
%
existing position position not existing
position planned to be established interested to collaborate with CTU
Function
# of Full Time Equivalents
Job Description / Please specify
%
existing position position not existing
position planned to be established interested to collaborate with CTU
Job Description
Please add a short description per function or attach existing job descriptions to the application.
2.2 Operations
- Please specify products and services delivered by the Institution/Organisation.
- Please give a summary on the day-to-day management of the Institution/Organisation.
- Please also answer the following specific questions:
– What are the procedures for allocation of resources to projects being conducted with the support of your Institution/Organisation? Is equal access to Institution/Organisation resources for different disciplines, other institutes/clinics available?
– How do you communicate within the Institution/Organisation and with other Institutions/Organisations? How do you envisage to coordinate local activities with other Institutions/Organisations in Switzerland and abroad?
– Please specify organisation of quality assessment and quality control.
– Please specify your internal/external training programme.
– Please specify how data-management is organised and which system is used within your Institution/Organisation.
3. Track Record
Please list/summarise important clinical research undertaken in your Institution/Organisation over the last five years (single/multi-centre trials, trials with industry sponsor or sponsor-investigator, do you also act as a sponsor-investigator, legal representative etc.)
4. Future Perspectives / expectations
State the motivation of your Institution/Organisation to become an associate member of the SCTO. Summarise the expectations your Institution/Organisation has in this regard.
Please list/summarise important projects, strategic plans etc of your Institution/Organisation for the future.