050.CV example for Investigators and Sub-Investigators

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050.CV example for Investigators and Sub-Investigators Powered By Docstoc
					                                                                                                                         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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