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NAME: Other: (please specify)
Site Signature Log/Delegation of Autority Log Version 1.0
DATES OF STUDY INVOLVEMENT:
l-related duties, as the Principal Investigator, I still maintain full responsibility f
Investi
ator Date:
Site Signature Log/Delegation of Authority Lo
Site Number: _____________
STUDY NAME
The purpose of this form is to: a.) serve as the ‘Site Signature Log" and b.) assure that the individuals performing study related tasks/procedures are appropriately trained and authorized by the Investigator to perform the task/procedure.
This form should be completed prior to the initiation of any study-related tasks/procedures. The original form should be maintained at your site in the study regulatory/study binder. This form should be updated during t
study as needed.
Please Print
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NAME:
I
Other: (please specify)
STUDY ROLE: SIGNATURE: INITIALS: DATES OF STUDY INVOLVEMENT:
NAME: Other: (please specify)
STUDY ROLE: SIGNATURE: INITIALS: DATES OF STUDY INVOLVEMENT:
NAME:
v
Other: (please specify)
STUDY ROLE: SIGNATURE: INITIALS: DATES OF STUDY INVOLVEMENT:
NAME:
v
Other: (please specify)
STUDY ROLE: SIGNATURE: INITIALS: DATES OF STUDY INVOLVEMENT:
NAME:
v
Other: (please specify)
STUDY ROLE: SIGNATURE: INITIALS: DATES OF STUDY INVOLVEMENT:
NAME: Other: (please specify)
STUDY ROLE: SIGNATURE: INITIALS: DATES OF STUDY INVOLVEMENT:
I certify that the above individuals are appropriately trained, have read the Protocol and pertinent sections of 21CFR 50 and 56 and ICH GCPs, and are authorized to perform the above study related tasks/procedures. Although I have
delegated significant tria or this trial.
Site Signature Log/Delegation of Autority Log Version 1.0
