<p> Form EXTERNAL USER ACCESS FORM</p><p>ASD-IT-0027 Version: 03 Effective date: 27 February 2018 Page 1 of 2</p><p>USER INFORMATION</p><p>Title: (MR. /MRS. /MS. /DR. etc) Date of Birth: (DD/MM)</p><p>First Name: Last Name: Primary Contact Sex: Male Female No: E-mail: </p><p>Protocol No: </p><p>Site No / </p><p>Name:</p><p>City: State / Province </p><p>Postal / Zip Country Code</p><p>Study Role: Investigator Coordinator Monitor Sponsor Other,______</p><p>INSTRUCTIONS TO COMPLETE FORM</p><p>1. Tick wherever required in the selection box 2. Complete your personal details in the areas provided 3. INCOMPLETE FORMS WILL NOT BE PROCESSED</p><p>TERMS & CONDITIONS</p><p>All personnel requesting access to SIRO Clinpharm Pvt. Ltd. Computer systems must complete and sign this agreement and send to Helpdesk Support Purpose: This document serves as a blanket confidentiality agreement for access to current and future systems.  The user must not, otherwise than in connection with the lawful exercise of his or her official functions, intentionally disclose, collect or use any confidential information about SIRO to which the user has or had access.  The sign on/ password assigned is unique to all the users and is non-transferable.  You have been trained on use of electronic system and password policy.  The user must make reasonable efforts to ensure the security of the physical and logical means of access provided.  Promptly notify Project Manager/ Line Manager and Apps Support ([email protected]) if you suspect that someone has gained unauthorized access to your sign on/ password.  The user is responsible for any information accessed or changed with the use of his/her sign on/password.  All access to and actions within SIRO systems will be logged and recorded.  The use of user id/password/electronic signature in all SIRO systems is deemed equivalent to physical signature and any errors/ falsification of data, electronically signed off, using password, will have the same legal consequences as signed off on an equivalent paper form.</p><p>I have read and agree to comply with SIRO Terms and Conditions as stated above.</p><p>User (DD | MMM | YYYY) Signature Date:</p><p>Confidential Please check that the version number is consistent with the current version number on the intranet. Form EXTERNAL USER ACCESS FORM</p><p>ASD-IT-0027 Version: 03 Effective date: 27 February 2018 Page 2 of 2</p><p>Monitor/ Reviewer Approval This is to certify that, D D M M M Y Y Y Y 1. The user has been trained on ______system on date 2. Valid information and signature has been provided by the user.</p><p>Approver Name </p><p>Signature and Date</p><p>Project Manager Approval</p><p>Grant access to all centers of this study. (In case of Sponsor/ Auditor etc.,)</p><p>Comments: </p><p>PM Name </p><p>Signature and Date</p><p>IT Confirmation</p><p>This is to confirm that access has been provided to the user as per the details provided</p><p>Access Manager </p><p>Signature and Date</p><p>Confidential Please check that the version number is consistent with the current version number on the intranet.</p>