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: *	Requestor's Name is Required
Email Address: *	Please enter a valid Email * *
Consortium: *	-- select -- BCED - Breast Cancer Early Detection BTC - Brain tumor consortium CPDPC - Chronic Pancreatitis, Diabetes, Pancreatic Cancer Consortium CVC - Clinical Validation Center GIMO - Gastrointestinal Medicine Oncology GUC - Genitourinary Cancer IND - Investigational New Drug IRB - Institution Review Board LCED - Lung Cancer early detection MCO - Multicenter Office MCRC - Multicenter Clnical Research Consortium MDSC - Myelodysplastic Syndrome Consortium PANC - Pancreatic cancer PATReC - The Pancreatic Ductal Adenocarcinoma Translational Resource Center (PATReC) THCCC - Texas Hepatocellular Carcinoma Consortium Required
Trial: *	-- select -- Required
Institution: *	-- select -- Required
Approver's Name: *	-- select -- Required

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

INSTRUCTIONS:

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.