CCDM Exam Application 2015 CCDM(临床数据管理认证)考试申请单

CCDMExamApplication2015CCDM(临床数据管理认证)考试申请单CCDMExamApplicationPleaseprovideresponsestoallcategorieswithinthisapplication*IndicatesrequiredresponsefieldSection1Pleaseenteryournameexactlyasitappearsonyourpassportorphotoidentification.*LastName:*FirstName:MiddleInitial:CurrentEmployer:Title:Department:*MailingAddress:*City:*State:*Zip/PostalCode:**Country:*DaytimePhone:*EveningPhone:Fax:*E-MailAddress:HaveyoualreadytakenthecurrentversionoftheCCDMexam?NoYesIfyes,whendidyoutaketheexam?AreyouamemberofSCDM?NoYesYoucanbecomeaSCDMmemberhere.SECTION2Group1(HighIncomeCountries)Group2(UpperMiddleIncomeCountries)Group3(LowIncome&LowerMiddleIncome)MembersNon-MemberMembersNon-MemberMembersNon-Member☐$250.00☐$325.00☐$200.00☐$250.00☐$125.00☐$200.00Methodofpayment:lVisalMasterCardlAMEXlCheckenclosedCreditCardNumber:_________________________________________ExpirationDate: ____________________________________________NameonCard: _____________________________________________Signature: _________________________________________________InordertoprocessyourexamapplicationwealsorequireacopyofyourCVtodeterminewhetherornotyouareeligibletosittheexam.PleasetickthisboxtoconfirmthatyouhaveincludedacopyofyourCValongwithyourapplication.Section3*Pleaseindicatethehighestdegreeyou'veearned.NoDegreeBSorBAMSorMAPhDOtherEducationalHistory-0EducationalInstitutionYearDegreeObtainedDegreeObtainedEducationalHistory-1EducationalInstitutionYearDegreeObtainedDegreeObtainedEducationalHistory-2EducationalInstitutionYearDegreeObtainedDegreeObtainedEducationalHistory-3EducationalInstitutionYearDegreeObtainedDegreeObtainedEducationalHistory-4EducationalInstitutionYearDegreeObtainedDegreeObtainedEducationalHistory-5EducationalInstitutionYearDegreeObtainedDegreeObtainedNumberofyears’experienceinCDMPleaseindicateCDMtasksperformedthroughoutyourworkexperience.ProtocolreviewProcessinglocallaboratorydata(collectedviaCRF)CRFDesignProcessing(loading/merging)centrallaboratorydataDataManagementPlandevelopmentMaintenanceoflaboratorynormalrangeinformationCRFtrackingandinventoryApplicationofrandomizationschemestostudydatabasesCRFdataverification(dataentrydiscrepancyresolution)DatabaselockproceduresCRFdatavalidationDatabasequalitycontrolauditsManualCRFreviewReviewoffinaldatalistingsQueryresolutionReviewoffinaldatatablesorgraphsQuerytrackingReviewoffinalreportsCommunicationofdatatrendsArchivingdatabaseandassociateddocumentationDatabaseupdatesCROmanagementSafetyreviewRelationalDatabasesCodingadverseevents/signsandsymptomsTimeManagementCodingmedicationsProjectManagementSAEreconciliation Section4ELIGIBILITYCERTIFICATIONIhavereadandunderstandtheEligibilityRequirements.IherebyrepresentandwarrantthatIameligibletoapplytotaketheCCDM®ExaminationbecauseImeettheeligibilityrequirements.RequiredAUTHORIZATIONIherebyauthorizetheSocietyforClinicalDataManagement(SCDM)tomakewhateverinquiriesitdeemsnecessaryandappropriatetoconfirmtheaccuracyofthecontentsofmyapplication.Iagreetoprovideanyadditionalauthorizationsnecessarytothatprocess.IherebyauthorizeSCDMtousetheinformationcontainedinmyapplicationandexaminationforpurposesofstatisticalanalysis,providedthatmypersonalidentifyinginformationhasfirstbeendeleted.RequiredAPPLICATIONINFORMATIONIherebycertifythatIhavereviewedtheinformationcontainedinthisapplicationandthatitiscompleteandtruthful.IunderstandthatmypresentingfalseorincompleteinformationmaybecauseforlossofeligibilitytotaketheCCDM®examination,fordenialofmyapplicationforcertificationorforrevocationofanycertificationgranted.RequiredEXAMINATIONIunderstandthatImaybedisqualifiedfromtakingorcompletingtheCCDM®examinationorfromreceivingexaminationscoresifSCDMdeterminesthroughproctorobservationorotherwisethatIengagedininappropriatebehaviourduringtheexamination.RequiredCLINICALDATAMANAGEMENTACTIVITYIherebyrepresentandwarrantthatIhaveatalltimesactedincompliancewiththeSCDMCodeofEthicsandwiththoselawsandregulationsapplicabletoclinicalresearch,includingwithoutlimitation,theDeclarationofHelsinkiandapplicableU.S.FoodandDrugAdministrationregulations.IunderstandthatconductinviolationofthespiritoftheCodeofEthicsorapplicablelawsmakesmeineligibletotakethecertificationexaminationandcanbecauseforpermanentrevocationofmycertificationstatus.RequiredSection5CONFIDENTIALITYAGREEMENTInconsiderationofyourparticipationintheexaminationprocessthatformsthebasisforSCDM’sCertifiedClinicalDataManagerCertificationProgram(“theProgram”),andtosetforthaclearunderstandingofyourobligationsrelatingtotheProgram,youagreeasfollows:(1)TopreservetheintegrityoftheProgram,youwillmaintaintestquestionsandyourknowledgeofthecontentsofandthesubjectmatteraddressedinthosequestions(“theTestQuestions”),inconfidenceandwillrefrainfromdisclosingorusingthem.(2)Yourobligationofnondisclosuredoesnotapplytosubstantiveinformationthatwasinyourpossessionpriortothisagreementorwhichbecamepublicthroughnofaultoromissiononyourpart,provided,however,thatyoumaynotdisclosetootherswhethersuchsubstantiveinformationisorisnotapartoftheProgram’scertificationexamination.YourobligationofnondisclosureshallalsonotapplyifyouarerequiredtodiscloseTestQuestionsinconnectionwithalegaloradministrativeproceeding,provided,however,thatyouagreetogivetheSCDMCertificationCommitteechairpromptwrittennoticeofsucharequest.(3)Allintellectualpropertyrights,includingwithoutlimitationallcopyright,arethesoleandexclusivepropertyofSCDM.SCDMshallhavetherighttoobtainandholdinitsnamerightsofcopyright,copyrightregistrationsandanysimilarprotection.(4)Allnondisclosureobligationsimposedbythisagreementshallterminateten(10)yearsfromthedateofthisagreement.(5)YourepresentandwarrantthatyouareempoweredtoenterintothisagreementandtograntandassigntherightsgrantedandassignedhereintoSCDM.Youfurtherrepresentandwarrantthatyouhavenotpreviouslygrantedorassigned,inwholeorinpart,toanyotherpersonorentity,includingwithoutlimitationyouremployer,anyoftherightsgrantedorassignedhereintoSCDM.(6)ThisagreementshallbeconstruedinaccordancewiththelawsoftheStateofWisconsin.Iherebyagreetothetermsandconditionsofthisconfidentialityagreement.Required