050.CV example for Investigators and Sub-Investigators by liwenting

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									                                                                                                                         2011
                         CV FORMAT BASED ON THE MCC REQUIREMENTS
                               Updated CV required per submission



 Format for CVs of Individuals Participating in the Conduct of Clinical Trials in South Africa

Trial:             __________________________________________________________

Protocol:          __________________________________________________________

Designation: __________________________________________________________
                   {e.g. National Principal Investigator, Investigator (Principal, Co- or sub), Study Co-ordinator,
                   Regional Monitor, Local Monitor, Contract Research Affiliate}


                                                      Curriculum Vitae


1. Personal details:

Name:                        ___________________________

Work Address:                ___________________________

                             ___________________________

                             ___________________________

Contact information:

Telephone no.:               ____________________________

Fax no.:                     ____________________________

Cell no.:                    ____________________________

E-mail address:              ____________________________


2. Academic and Professional Qualifications:

                   ________________________________________

                   ________________________________________

                   ________________________________________


3. Health Professionals Council of South Africa (HPCSA) registration number:
   {If applicable (or other health professions body registration particulars –
   e.g.. Nursing Council}

                   ________________________________________


University of the Witwatersrand, Secretariat to Human Research Ethics Committee (Medical) – CV Template based on MCC Format

D:\Docstoc\Working\pdf\da6b6bca-ed18-4028-82bf-3c8bab0be3c4.doc
REF: SOP-IEC-002
                                                                                                                      Page 1 of 2
                                                                                                                        2011
                        CV FORMAT BASED ON THE MCC REQUIREMENTS
                              Updated CV required per submission

4. Current Personal Medical Malpractice Insurance Details:
   (Medical and Dental Practitioners)
   ___________________________________________________

5. Relevant related work experience (brief) and current position:

   ____________________________________________________

   ____________________________________________________

   ____________________________________________________

   ____________________________________________________

6. Participation in clinical trials research in the last three years
   (title, protocol number, designation) {If multiple trials, only list those with relevance
   to this application, or in the last year}:

   ____________________________________________________

   ____________________________________________________


7. Peer reviewed publications in the past 3 years.
   ____________________________________________________

   ____________________________________________________

   ____________________________________________________

   ____________________________________________________

8. Date of last GCP training (as a participant or presenter). Please supply Name of Course.
   (dd/mmm/yyyy) - and Name of GCP course and/or presented by (Company/Person)

   ____________________________________________________

   Please note: Kindly attach a copy of certificate of GCP Course attended. Training at
   Investigator’s Meeting and/or Start up Meeting do not imply having attended a GCP Course.
                                                                               Ref: SOP.IEC.011

9. Any Additional relevant information supporting abilities to participate in conducting this
   trial {briefly}

    ____________________________________________________


Signature: ____________________________                           Date: _____________________




University of the Witwatersrand, Secretariat to Human Research Ethics Committee (Medical) – CV Template based on MCC Format

D:\Docstoc\Working\pdf\da6b6bca-ed18-4028-82bf-3c8bab0be3c4.doc
REF: SOP-IEC-002
                                                                                                                    Page 2 of 2

								
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