Form 5 Roster Update

Attachment_A05_ruf

OMB# 0925-0753
Expiration Date 07/31/2021

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OMB# 0925-0753
Expiration Date 07/31/2021

Attachment_A5_ruf

CTSU ROSTER UPDATE FORM
Please note that all persons added to the CTSU site rosters must have an active status with NCI and on a network
roster. Individuals assigned the CTSU Administrator or Data Administrator must hold a registration type of
Associate Plus or higher. To register in the Registration and Credential Repository (RCR) go to
https://ctepcore.nci.nih.gov/rcr.
Network Updates:
Individuals added to the CTSU institution rosters must be active on a network treatment roster of the
institution.
Roles may be assigned to the person by the Site Administrator or Site Data Administrator viathe
CTSU members’ web site at https://www.ctsu.org/public/Default.aspx under the RUMS tab.
Upload the form to the Regulatory Submission Portal at www.ctsu.org. Select the Membership/Supply
document type.
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 one person may hold either the Site Admin or Data Admin role at an institution; a person must
have the Associate Plus registration type to hold either of these roles.)
CTEP
Person
Site Name Institution
Role (Admin
Add
Delete Delete
Name
Person
Role
Role &
Code
or DA)
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:
Person submitting form:

Date:
Date:

Final_July_2018
Authorized by CTSU for local reproduction

CTEP ID