MDA Online User Access Request

Online User Access Request

Complete this form for all users who are performing clinical trial management activities or requiring access to the clinical trial management applications. The access will be only granted to users who have submitted this form.

Note: This request must be approved by a designated approver before being processed. 

Enter required details: 
Requestor's Name: *
Email Address: *    
Consortium: *  
Trial: *  
Institution: *  
Approver's Name: *  

Enter each user’s information below. Click the ‘+’ sign to add more users:


If a user selects one of the choices from 'For Licensed Clinicians Only' below, the user is required to have a valid medical license number during the next step once an account is established. If the user is an unlicensed doctor, please do not select this option.

NoFirst NameLast NamePhone NumberEmail AddressFor Licensed Clinicians Only 
1         Remove