C5R Membership Application Form Application for Membership in the Consortium of Canadian Centres for Clinical Cognitive Research (C5R) Step 1 of 6 16% C5R MISSION C5R’s mission is to facilitate collaborative clinical cognitive research in Canada; to establish a forum for the exchange of information relevant to research in cognitive disorders; to consider and make recommendations upon the methodologies of clinical cognitive research and to advocate for appropriate treatment of clinical cognitive disorders; to provide consensus opinion upon clinical and research issues as may most expediently benefit the health of the Canadian population, including guidelines for practice; and to develop liaisons with agencies supporting cognitively impaired patients.Benefits of Membership Include: Enhanced efficiency in the procurement of trials for investigators. Providing a communication network for all clinical researchers interested in dementia across Canada. Negotiating a common patient budget. This relieves the need for individual negotiations with pharmaceutical companies. The abiding principle is that all members receive equal compensation for equal work performed. Surplus funds of the C5R could be applied to promote the development of multicentre investigator driven trials. The C5R could be influential in modifying the design of clinical protocols being proposed by pharmaceutical companies. Conditions of Membership No member shall have been sanctioned or disciplined by any medical professional regulating body. All members shall provide such reasonable and continuing financial disclosure as C5R’s Board of Directors may require from time to time. All members shall comply with any reasonable conditions of membership imposed by C5R’s Board of Directors, including the payment of any reasonable membership fees or dues. Obligations of Membership, all members agree to: Pay annual dues as determined by the C5R Board of Directors. With respect to clinical trial negotiations with drug companies, members will not deal directly and/or autonomously with individual pharmaceutical companies. Members shall direct all such enquiries to the C5R secretariat office. Every member will be notified of all clinical trials presented by a Sponsor, but the ultimate decision to select a clinical trial site will be determined independently by the sponsor. Sponsors will be provided with a list of all C5R members interested in their trial. If members choose to participate in clinical trials outside the Consortium, they will forego membership until that particular clinical trial finishes (as defined by closeout visit completed). During such time, the member shall not receive any of the benefits of membership and will be required to certify that such outside clinical trial has been completed before membership shall re-commence. All members are required to abide by the terms of any blanket corporate confidentiality agreements executed by the Consortium Chairperson(s), on behalf of the Consortium members and the organization at large. A clinical trial centre where a C5R member anticipates conducting clinical research will have to provide sponsors with a history of past trial experiences, local resources available (freezers, centrifuge etc.) and other information (e.g. trial completions etc.), as becomes necessary to be incorporated into the database for each centre. An annual meeting of the C5R members will be held. Protection of Privacy Information The C5R complies with the principles of the Personal Information Protection and electronic Documents Act (PIPEDA). We will use the personal information collected on this form for processing your membership application. Once it is approved, unless you advise the C5R secretariat office otherwise, we will use your contact information to: disseminate society information, conduct society business, include in the C5R membership directory (online), and for member lists occasionally provided to non-commercial and affiliated organizations deemed appropriate by the C5R. The information below will appear in the Membership Directory (member access only) on the C5R websitePrefixFirst Name*Last Name*Title*Organization*Address* Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Phone*(123)123-1234ExtensionFaxEmail*WebsiteC.V.*Accepted file types: doc, docx, pdf, rtf, txt.Please upload a copy of your most current C.V. in PDF, Ms Word, rich text format or plain text format.Membership Type(s)* Principal Investigator Co-Investigator Associate Member Principal Investigator Membership ApplicationComplete the following fields to apply as a Principle Investigator with C5RDiscipline*NeurologistBehavioural NeurologistGeriatricianPsychiatristGeriatric PsychiatristFamily PractitionerOtherDiscipline - Other:*Type of Research Site*AcademicPrivateResearch Site Name*Overhead (%)*Please enter a value between 0 and 100.Please indicate and document how you meet the criteria for PI membership. To be eligible PI’s must meet 2 of the following 3 criteria.1. Adequate training in cognition and/or cognitive clinical research 2. Clinical cognitive research experience (phase 11 or 111a clinical trials or equivalent) 3. Major clinical practice focus on cognitive impairment/dementia as demonstrated by a commitment of 33% or more of your time to this field over a period of at least 1 -2 years. My review board is*LocalCentralIdentify specifically the Review Board that approves your studies:*The Membership Committee will review applications for site PI even if the applicant does not appear to meet the required criteria if the application is accompanied by supporting documentation explaining why the application should be viewed favourably.Upload Supporting DocumentationAccepted file types: pdf, doc, docx, rtf, txt.You may upload your documentation in PDF, MS Word, Rich text or Plain text format.Name of Research Coordinator(s) If you are applying for PI Membership, your research coordinator (s) must apply for separate “Associate” Membership. Co-Investigator Membership ApplicationComplete the following fields to apply as a Co-Investigator with C5R $50.00 Annual fees (do not pay now, your fees will be prorated to the date of membership approval) are M.D.’s and/or Ph.D.’s who have distinguished themselves by their competence in clinical cognitive disease, or by the quality of their research in clinical or in basic scientific aspects of cognitive disease. Full members will have been actively engaged in clinical cognitive research activities for a period of at least one year. Research Site Name*Research Site Principal Investigator (PI)*Co-Investigator's Discipline*NeurologistBehavioural NeurologistGeriatricianPsychiatristGeriatric PsychiatristFamily PractitionerOtherDiscipline - Other:* Associate Member ApplicationComplete the following fields to apply as an Associate Member with C5R$25.00 (fees will be invoiced and prorated from date of membership approval) are nurses, research assistants, research trainees, managers, accountants, who are actively involved in the practice of cognitive research. Research Site Name*Research Site PI*Research Coordinator*SelfCITI Certification*YesNoSoCRA Certification*YesNo Upon admission, all Members shall have the right to attend the annual meeting and all general and special meetings of the Consortium. Individual classes of Members shall also have the following rights and obligations: (a) Upon admission, PIs’ shall have the right: (i) to vote on changes to the by-laws and Letters Patent of the Consortium; (ii) to stand for election to the Council; (iii) to vote in elections for the Council; (iv) to receive copies of all communications that the Consortium from time to time prepares for its Members; and (v) to vote on matters pertaining to the business of the Consortium. Upon admission, PIs’ shall be obliged: (i) to pay dues as set by the Consortium; Upon admission, PIs’ shall be invited: (i) to participate in C5R’s scientific reviews of study protocols (b) Upon admission, Co-Investigators’ shall have the right: (i) to vote on changes to the by-laws and Letters Patent of the Consortium; (ii) to stand for election to the Council; (iii) to vote in elections for the Council; (iv) to receive copies of all communications that the Consortium from time to time prepares for its Members; and (v) to vote on matters pertaining to the business of the Consortium. Upon admission, Co-Investigators’ shall be obliged: (i) to pay dues as set by the Consortium; Upon admission, Co-Investigators’ shall be invited: (i) to participate in C5R’s scientific reviews of study protocols (c) Upon admission, Associate Members shall have the right: (i) to receive copies of all communications that the Consortium from time to time prepares for its Members; (ii) to elect one representative to the Council; Upon admission, Associate Members shall be obliged: (i) to pay dues as set by the Consortium. Upon admission, Associate Members shall be invited: (i) to participate in C5R’s scientific reviews of study protocols Transferability of membership A membership may only be transferred with the approval of the C5R Board of Directors.PhoneThis field is for validation purposes and should be left unchanged.