fGSK InForm study - Access Management Form

For fGSK InForm studies(Urgent Requests Only)

Email this form to: Web Address:

Instructions for completing this form:

Urgent Access/Modification: if Urgent access is needed, the user can contact one of the following study approvers per study:

TDM

PCDM

DQL

CTH

GMO

The study approver will complete the form and will confirm the user has completed their required trainings, by ticking the training certification box at the bottom of the form and sign (Important: enter your First and Last name as it appears on your email address), date, scan and email to the Novartis Oncology Helpdesk () to request the urgent access.

Once access is granted, the study approver will contact the user to provide them with their InForm UserID, generic password and Inform Study URL. In addition, the study approver will send an email to the TCS Access team: ; ; ; , to request they associate the new user to the study center(s) in eTrack.

*Required InformationProtocol Number*(fGSK protocol number, one study per form): (e.g. XYZ123456)

Centre Number*: (site users only)

User Detail(one user per form)

First Name: Last Name:

Email: Phone

Country

InForm

Current InForm username: (required for existing users)

Add new Site User with Enter Rights Group Here

Requested username(initial of first name + last name)

Add new User with Enter Rights Group Here

Requested username (rights group prefix + MUDID)

All Centres or Select Centre(s):

Terminate existing user account

Add additional centre(s) to existing user account:

Remove centre(s) from existing user account:

Change rights group for existing useraccount from:

Enter Old Rights Group Here

to:

Enter New Rights Group Here

NB: If changing to/from “Other, specify” roles, please provide details in Additional Comments selection below

Un-terminatetheuser account: username to rights groupEnter Rights Group Here

Grant or Remove access to InForm Portal

Additional Comments(Please use this section to clarify requests that may need further explanation.)

Authorisation

This form is beingissued in anURGENT situation that requires immediate attention. I understand that non-urgent requests should be initiated through eTrack and the normal user access management process.

When this form is submitted by email, it will be sent from the Novartisemail account of the person listed below.

NOTE: The person listed below must have the proper role/authority within the study to make the requested changes or the form will be rejected.

IMPORTANT: After submitting this form, allinformation must be entered into eTrack. If this is not done, changes resulting from this form may be deleted when a future MUL is processed.

Training certification (*you must ensure that Inform training has been delivered):

I confirm that InForm training has been delivered for this user (tick here):

Role*: Enter Role

First Name*: Last Name*:

Email Address*: Date*:

If your role is not in the above list please confirm with your email when submitting the request. We may need additional authorization in some cases.

Novartis Oncology HelpdeskUse Only:

CRMS Incident Number / Support Confirm Addition? / Verify users have access?
Processed by UM : / Processed by UA: / Date:
Checked by (Sign and date) / AMF 8 Jan 2016