C5R Membership Application Form

Application for Membership in the Consortium of Canadian Centres for Clinical Cognitive Research (C5R)

Step 1 of 8

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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:
1. Enhanced efficiency in the procurement of trials for investigators.
2. Providing a communication network for all clinical researchers interested in dementia across Canada.
3. 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.
4. Surplus funds of the C5R could be applied to promote the development of multicentre investigator driven trials.
5. The C5R could be influential in modifying the design of clinical protocols being proposed by pharmaceutical companies.
Conditions of Membership
1. No member shall have been sanctioned or disciplined by any medical professional regulating body.
2. All members shall provide such reasonable and continuing financial disclosure as C5R’s Board of Directors may require from time to time.
3. 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:
1. Pay annual dues as determined by the C5R Board of Directors.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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 website
Prefix
First Name*
Last Name*
Title*
Organization*
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
(123)123-1234
Extension
Fax
Email*
Website
C.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
- Fellow Member
- Subspecialty Resident Member

Principal Investigator Membership Application
Complete the following fields to apply as a Principal Investigator (PI). $500 annual fee for a Research Site/PI membership (do not pay now, your fee will be prorated to the date of membership approval). PIs are M.Ds and/or Ph.Ds 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.
Discipline*
Discipline - Other:*
Type of Research Site*
- Academic
- Private
Research 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*
- Local
- Central
Identify 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 Documentation
Accepted 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 Application
Complete the following fields to apply as a Co-Investigator with C5R
$50.00 Annual fee for a Full/Co-Investigator membership (do not pay now, your fee will be prorated to the date of membership approval). Co-Investigators are M.Ds and/or Ph.Ds 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.
Research Site Name*
Research Site Principal Investigator (PI)*
Co-Investigator's Discipline*
Discipline - Other:*

Associate Member Application
Complete the following fields to apply as an Associate Member with C5R
$25.00 annual fee for an Associate membership (do not pay now, your fee will be prorated to the date of membership approval). Associate members are nurses, research assistants, research trainees, managers, accountants, who are actively involved in or supporting the practice of cognitive research.
Research Site Name*
Research Site PI*
Research Coordinator*
Self
CITI Certification*
Yes
No
SoCRA Certification*
Yes
No

Fellow Member Application
Complete the following fields to apply as a Fellow Member with C5R. There is no fee associated with a Fellow Membership.
Research Site Name*
Research Site PI*
Research Coordinator*
Self
CITI Certification*
Yes
No
SoCRA Certification*
Yes
No

Subspeciality Resident Member Application
Complete the following fields to apply as a Subspeciality Resident Member with CSR. There is no fee associated with a Fellow Membership.
Research Site Name*
Research Site PI*
Research Coordinator*
Self
CITI Certification*
Yes
No
SoCRA Certification*
Yes
No

Upon admission, all Members shall have the right to attend the annual meeting.

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 CSR's CIRCL protocol reviews, after participating as an unpaid observer on one review.

(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 CSR's CIRCL protocol reviews, after participating as an unpaid observer on one review.

(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 CSR's CIRCL reviews of study protocols, after participating as an unpaid observer on one review.

(d) Upon admission, Fellow and subspecialty resident Members shall be invited:

(i) to participate in C5R's CIRCL reviews of study protocols as an unpaid observer, under C5R's central Non-Disclosure agreement with the study sponsor (or CRO).

Transferability of membership

A PI, Co-Investigator, or Associate Membership may only be transferred with the approval of the CSR Board of Directors.
A Fellow or subspecialty Resident Membership may not be transferred .
Phone
This field is for validation purposes and should be left unchanged.

Application for Membership in the Consortium of Canadian Centres for Clinical Cognitive Research (C5R)

Step 1 of 8

Principal Investigator Membership Application

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.

Co-Investigator Membership Application

Associate Member Application

Fellow Member Application

Subspeciality Resident Member Application