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Page Delegation Log of Protocol Title: Protocol Number: Sponsor: Principal Investigator (PI): NAME, CREDENTIALS INITIALS SIGNATURE RESPONSIBILITIES START DATE END DATE PI INITIALS PI: RESPONSIBILITIES 01: Informed Consent 05: Subject Interviews 09: Drug Reconciliation 13: Data monitoring 02: Assess Eligibility Criteria 06: Perform Physical Exam 10: Adverse Event Assessment 03: Obtain medical history 07: Drug/Device Dispensing 11: Adverse Event Documentation/Reporting 14: Safety monitoring 15: Other 04: CRF Entries 08: Drug Administration 12: Maintain Regulatory Documents Investigator’s Authorization: I hereby delegate the above significant research-related duties to the following persons and understand that the overall responsibility for conduct of the research remains with me. 1Investigator’s Signature: VERSION March 2012 Corresponds to REG 106- Delegation of Authority/Responsibility Date:
