Special Interest Group for Clinical Trial Network Managers (SIGNet) – Member Details Special Interest Group for Clinical Trial Network Managers (SIGNet) – Member Details Title Name Name First Name First Name Last Name Last Name Organisation/ Clinical Trial Network (CTN) Work Address City State Post Code Country Work Phone Email Current position title Which of the following professional categories best describes your role? (Please select one option only) CTN Manager Project Officer/ Coordinator How long have you been in your current role? Please provide the name of the tertiary institute, peak body or external organisation that your CTN is aligned with: What is your CTN’s main therapeutic area? Is your CTN: Facilitating Centre Coordinating Centre What is your CTN’s main therapeutic area? What phase and/or type of research does your CTN conduct? Phase III All of the above How many members does your CTN have? (i.e.professional/clinical members as compared to employees) 10-50 >50 What skills or expertise do you have which supports SIGNet? (Please select all that apply) Leadership Finance/Budgeting Grant writing Ethics submissions Establishing a new CTN Governance Policy Communication/Marketing Stakeholder Engagement Consumer Engagement Other (please specify): What are your areas of interest and what would you like to learn more about by being a member of SIGNet? (Please select all that apply) Leadership Policy Fundraising Finance/Budgeting Governance Grant writing What would you like to achieve through being a member of SIGNet? Please provide a response to this question rather than using “no comment” or “N/A”. What activities is your CTN working on that would be of interest to other SIGNet members? What challenges are you facing at your CTN? (excluding funding or grant writing) SIGNet are looking to set up a mentorship program. Please indicate whether you would like to be involved. Yes- Interested in being a Mentee Yes – Interested in being a Mentor Yes- Interested in being both a Mentor and Mentee No- Not interested SIGNet are looking to set up a directory for members only to reach out for support, networking, discussion andmentorship. Please indicate whether you would like to belisted. Yes No Are you or your organisation a member of ACTA? Yes- Organisation Member No Would you like to be added to our monthly ACTA newsletter to be informed of sector news and events? Yes No Submit If you are human, leave this field blank. Δ
