<p> SITE PERSONNEL SIGNATURES & DELEGATED RESPONSIBILITIES Investigator: ______Project: ______Study Site: ______Sponsor: ______</p><p>NAME TITLE OR TASK* SIGNATURE INITIALS DATES (PRINT OR TYPE) POSITION CODES (OF WORK ON STUDY) PI’s Codes Initials From: To:</p><p>From: To:</p><p>From: To:</p><p>From: To:</p><p>From: To:</p><p>From: To: d</p><p> e A = Make eligibility/termination decisions E = Evaluate adverse events (cause/severity) Other Tasks** t a</p><p> g B = Obtain informed consent F = Prescribe study drugs/devices I= ______e</p><p> l </p><p> e C = Direct medical care of subject G = Label and dispense study drug J= ______</p><p>D (treatment decisions) K= ______D = Make data entries and corrections H = Maintain drug/device accountability records on CRFs L= ______* s e</p><p> i **List all other key protocol tasks, e.g., administer study drug, draw bloods, physical exams, etc. t i l i b i s n o p s e R</p><p>Compliments of:</p><p>SMART Site Monitoring, Auditing and Review Team VA Cooperative Studies Program Albuquerque, NM 1/30/07</p><p>TO BE SIGNED AT SITE CLOSURE: I confirm that this list accurately reflects the delegation of responsibilities during the trial. Investigator Signature: ______Date: 2 0 0 D D M M M Y Y Y Y</p><p>Compliments of:</p><p>SMART Site Monitoring, Auditing and Review Team VA Cooperative Studies Program Albuquerque, NM 1/30/07 </p>