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10-CBA DELEGATION OF RESPONSIBILITY & STAFF SIGNATURE LOG
CIBMTR CENTER # CENTER NAME PI Name:
Designee Full Name(printed)
Title(PI, Sub-I,
coordinator, data manager, etc.)
Designee Initials
Designee Signature Delegated Activities(see codes
below)
Effective Date
End Date
# of years clinical
research experience
Completion date ofHuman Subjects
Protection training
Study Activity Codes: 1. Medical History/ Physical Exam (Patient Care)2. Drug Dispensing/Accountability3. Query Resolution
4. Recruiting/screening5. Consenting/enrollment 6. Data collection (direct subject contact)7. Adverse Event Assessment (Physician only)
8. Study form Completion (including unscheduled forms)9. Maintaining study files 10. Other-specify
Investigator’s Authorization: As Principal Investigator for the above mentioned investigational trial, I authorize the above staff to assume the indicated responsibilities. I understand that this in no way alters my responsibilities as defined in the Code of Federal Regulations, Title 21 CFR Part 50, 56 and 312.
Investigator’s Signature: Date: _________________
In the case of log revisions, please re-sign and date:
Investigator’s Signature: Date: _________________
Investigator’s Signature: Date: _________________