Non-IACET CEU Affidavit Form

For non-SCDM educational offerings, applicant must sign affidavit below and include all course materials, brochure and/or advertisement of course as well as a corroborating reference signature.

Affidavit Requirement

I _____________________ verify under penalty of revocation, that I successfully

completed the course titled _____________________________

offered by (Institution)_____________________________

on the dates of _____________________________

Duration of course* ______________

Participant Signature_____________________________ Date ______________

Reference Signature _____________________________ Date ______________

* excludes break and meal times

Attachments required for approval

1. Printed description and details provided by the educator2. Speaker information (Bio/Curriculum Vitae)3. Attendance Verification (A Certificate of Completion is the only verification

acceptable)

Please indicate below which chapters within the GCDMP were covered throughout your course:

1. Data Privacy ☐2. Data Management Plan ☐3. Project Management for the Clinical Data Manager ☐4. Vendor Selection and Management ☐5. Data Management Standards in Clinical Research ☐6. Design and Development of Data Collection Instruments ☐7. Edit Check Design Principles ☐8. Electronic Data Capture—Concepts and Study Start-up ☐9. Electronic Data Capture—Study Conduct ☐10.Electronic Data Capture—Study Closeout ☐11.CRF Completion Guidelines ☐12.CRF Printing and Vendor Selection ☐13.Database Validation, Programming, and Standards ☐14.Laboratory Data Handling ☐15.External Data Transfers ☐16.Patient-Reported Outcomes ☐17.CDM Presentation at Investigator Meetings ☐18.Training ☐19.Metrics in Clinical Data Management ☐20.Assuring Data Quality ☐21.Measuring Data Quality ☐22.Data Storage ☐23.Data Entry Processes ☐24.Medical Coding Dictionary Management and Maintenance ☐25.Safety Data Management and Reporting ☐26.Serious Adverse Event Data Reconciliation ☐27.Database Closure ☐28.Clinical Data Archiving ☐29.Glossary ☐

Additional Comments: ___________________________________________

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