Application for Reimbursement of Certification And/Or Membership Fees

Alliance Coordinator Award Program

Application for Reimbursement of Certification and/or Membership Fees

New Application Renewal

Applicant

Name: / Phone #:
Dept/Div: /

Fax:

Affiliation: / Email:
(Hospital/Facility)
Address to which correspondence should be mailed:
Name of Principal Investigator/Study Team:
Seeking reimbursement for (choose one): ACRP Certification SOCRA Certification
Seeking reimbursement for (choose one): ACRP Membership SOCRA Membership
Do you currently coordinate clinical research studies? Yes No
How many clinical research protocols have you worked on in the past 12 months?
How many clinical research protocols do you expect to work on in the next 12 months?
Clinical Research studies include (check all that apply)
Interventional Clinical Trials Social/Behavioral Research Observational Research
Chart Reviews Laboratory Based Studies
Clinical Research activities include (check all that apply)
Regulatory Document Management Submission to the IRB Conducting Study Procedures
Obtaining Informed Consent Recruitment Budgeting and Financial Management
Do you serve on any health system or departmental committees relating to research? Yes No
If yes, provide name of committees and dates of service:
Have you published or presented the results of your research? Yes No
If yes, provide details:
Education and Training
Highest degree earned, Institution, and year:
Have you attended any NSLIJHS research education programs in the past 12 months: Yes No
If, yes please list courses:
Have you attended any external research education programs in the past 12 months: Yes No
If, yes please list date, course name, and organization providing training:
Have you attended any conference on clinical research in the past 12 months: Yes No
If, yes please list date, conference name, and organization sponsoring the event:
Date of completion: CITI training for Human Subject Protections
Date of completion: CITI training for Good Clinical Practice (GCP)

Attach a copy of the application submitted to ACRP or SOCRA

Attach a copy of your current CV or NIH Biosketch

Attach a copy of receipts for registration and/or membership fees

Principal Investigator/Department Chair Recommendation

By signing below, I acknowledge that I have reviewed this coordinator’s application, CV, and credentials and recommend him/her for an Alliance Coordinator Scholarship based on performance

Recommended by (print name): ______

Signature: ______Date ______

Applicant Attestation

By signing below, I attest that all of the information provided is accurate as of the date of signature. I understand that any deliberate misrepresentation may subject me to disqualification and potential disciplinary action.

Name of Applicant (print name): ______

Signature: ______Date ______

Alliance Coordinator Awards

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