Application form for associate membership
Date of submission:
Please note: since this application will be subject to internal review, the application form and
preferably all accompanying documents must be completed in English.
1. Basic data
Name of institution /
organisation
Contact Person
Surname, first name
Academic degree
Position
Address, No.
ZIP, City
Direct line
Office line
Fax
E-mail
Host Institution
(if applicable)
(institution which will host the CTU and may provide necessary support)
Name of Institution
Address, No.
ZIP, City
Office line
Fax
E-mail
Advising full member
(if applicable)
Name of Institution
Address, No.
ZIP, City
Office line
Fax
E-mail
(institution which advises the applicant and will provide necessary support)
Application form for associate membership – version date: 140415
Contributing Authors
(if applicable)
2
(other persons beside the designated Contact Person who contributed substantially
to the conceptual work and/or writing of the application)
Surname, First Name
Institute/Department
Type of Contribution
Surname, First Name
Institute/Department
Type of Contribution
Confirmation by Contact Person
I hereby confirm that all the details given in this proposal, including the appendices, are correct. They were
elaborated jointly with all co-authors, the host institution and the advising full member of the SCTO.
Place, date:
Signature:
Please include the following documents with the application (where appropriate):
letter of recommendation from the Director of the host institution
other (please specify)
Name institution:
Application form for associate membership – version date: 140415
3
2. Organisation
2.1 Organisational Structure, Organigram, and Overview of Functions
and Competences

Please provide an organigram of your Institution/Organisation.

Please specify how the necessary competence in clinical study design, trial management, epidemiology,
pharmacology, biostatistics, databank design and handling, nursing, and other disciplines to be covered is
reached.

Please provide a short job description for each function listed on the organigram of your CTU. Where appropriate, indicate names and professional background of position holders.

Please specify, whether are interested to collaborate with a CTU from the CTU network and if yes, in which
field(s)
Institution/Organisation Personnel
Function
# of Full Time Equivalents
Job Description
Head/Coordinator of Institution/Organisation
%
existing position
position planned to be established
Function
# of Full Time Equivalents
Job Description
Biostatistician
%
existing position
position planned to be established
Function
# of Full Time Equivalents
Job Description
position not existing
interested to collaborate with CTU
Study Nurse
%
existing position
position planned to be established
Name institution:
position not existing
interested to collaborate with CTU
Study Manager/Monitor
%
existing position
position planned to be established
Function
# of Full Time Equivalents
Job Description
position not existing
Quality Manager
%
existing position
position planned to be established
Function
# of Full Time Equivalents
Job Description
position not existing
interested to collaborate with CTU
Secretary / Clinical Trial Administrator
%
existing position
position planned to be established
Function
# of Full Time Equivalents
Job Description
position not existing
position not existing
Application form for associate membership – version date: 140415
Function
# of Full Time Equivalents
Job Description
Data Manager
%
existing position
position planned to be established
Function
# of Full Time Equivalents
Job Description
position not existing
interested to collaborate with CTU
Clinical Epidemiologist
%
existing position
position planned to be established
Function
# of Full Time Equivalents
Job Description
4
position not existing
interested to collaborate with CTU
Clinical Pharmacologist
%
existing position
position planned to be established
position not existing
interested to collaborate with CTU
Add other functions as needed
Function
# of Full Time Equivalents
Job Description
Please specify
%
existing position
position planned to be established
Function
# of Full Time Equivalents
Job Description
position not existing
interested to collaborate with CTU
Please specify
%
existing position
position planned to be established
position not existing
interested to collaborate with CTU
Job Description
Please add a short description per function or attach existing job descriptions to the application.
Name institution:
Application form for associate membership – version date: 140415
5
2.2 Operations

Please specify products and services delivered by the Institution/Organisation.

Please give a summary on the day-to-day management of the Institution/Organisation.

Please also answer the following specific questions:
–
What are the procedures for allocation of resources to projects being conducted with the support of your
Institution/Organisation? Is equal access to Institution/Organisation resources for different disciplines,
other institutes/clinics available?
–
How do you communicate within the Institution/Organisation and with other Institutions/Organisations?
How do you envisage to coordinate local activities with other Institutions/Organisations in Switzerland
and abroad?
–
Please specify organisation of quality assessment and quality control.
–
Please specify your internal/external training programme.
–
Please specify how data-management is organised and which system is used within your Institution/Organisation.
Name institution:
Application form for associate membership – version date: 140415
3. Track Record
Please list/summarise important clinical research undertaken in your Institution/Organisation over the last five years
(single/multi-centre trials, trials with industry sponsor or sponsor-investigator, do you also act as a sponsorinvestigator, legal representative etc.)
Name institution:
6
Application form for associate membership – version date: 140415
4. Future Perspectives / expectations
State the motivation of your Institution/Organisation to become an associate member of the SCTO. Summarise the
expectations your Institution/Organisation has in this regard.
Please list/summarise important projects, strategic plans etc of your Institution/Organisation for the future.
Name institution:
7