EDGE Site Implementation In-Take Form
Please complete the information below. This will allow us to accurately setup your EDGE organizational
structure, evaluate the scope and understand your expectations. Each NCC and NACC will need to
complete this form individually and submit to [email protected].
Date: Enter a date.
Form Completed By: Enter name.
SECTION 1: REQUIREMENTS
Cost & Legal Requirements
The EDGE access fee is $12,000/year for the region. If the NCC pays the full access fee amount, all its
associated NACCs will have access to EDGE. 3CTN encourages the NCC to discuss EDGE implementation
with its NACCs and discuss a cost sharing strategy (if applicable).
☐Cost sharing strategy finalized within regional node (NCC and NACCs)
EDGE Access Fee paid by:
Enter site name.
Fee amount to be paid:
Enter amount (e.g., $12K/year or other).
If you are an NCC, does the access fee cover your NACCs within your node? Select one.
☐Agreement with EDGE UK and OICR signed. If not signed, estimated completion date: Enter a date.
Technical Requirements
☐Internet Access
Browser: ☐IE8 and above preferred ☐Google Chrome ☐Firefox ☐Safari ☐Other: List other browsers.
Human Resources
☐Dedicated lead organization administrative user identified and available
Name:
Enter name of lead admin user.
Email Address:
Enter email address of lead admin user.
SECTION 2: EDGE SET UP INFORMATION (academic and non-academic trials)
# of investigators at your site:
Enter number.
# of estimated active users (view and date entry required):
Enter number.
# of active cancer clinical trials (open, pending, close to accrual but still in follow
up):
Enter number.
# of new patients recruited per year
Enter number.
# of estimated active patients per year (including patients on follow up)
Enter number.
Trial documents for storage (check all that apply):
Note: no patient files should be stored, refer to the privacy regulations.
☐Protocol
☐Consent Form (blank)
☐Templates
☐SOPs
☐Other: List additional documents for storage.
Version 1.4
Page 1
List
List
List
List
examples
examples
examples
examples
of
of
of
of
work processes to be tracked (e.g., Annual Renewal):
work processes to be tracked.
current and future reports needed:
current and future reports needed.
Target Go Live Date: Enter a date.
SECTION 2: CONTACT INFORMATION
Primary Contact for Implementation
Name: Enter applicant name.
Title: Enter applicant title.
Phone Number: Enter phone number.
Email: Enter email.
Organization Information
3CTN Site Type: Select one.
Organization:
Enter the organizational legal name for EDGE and the contract.
Address:
Enter address.
Telephone Number:
Enter phone number.
Website:
Enter website url.
Finance Department Contact for Invoicing Queries
Name:
Enter finance department contact name.
Telephone Number:
Enter phone number.
Email Address:
Enter email address.
Purchase Order Number:
Enter purchase order number, if available.
Version 1.4
Page 2