ACTRI Clinic Access Request Form

ACTRI Clinic Access Request Form
Are you completing this request for someone else? *

Yes No
Please do not continue if you are attempting to complete this request form for someone else. The request form is created in a way where each response is specific to an individual. Instead, we recomment that you forward the link below to the person who needs access and have them complete it for themself.

https://ucsd-actri.jotform.com/211674870051857

Please contact ctri-clinic@health.ucsd.edu for any questions regarding the form.

-- Clinic Badge Access Section
Clinic Badge/Clinical Conductor Access:

Complete the CITI Good Clinical Practice (GPC) course here CITI Program

Your organization is: University of California, San Diego

Additional Reading: Good Clinical Practices (GCP) Training Requirements

Certificate Example: https://ucsdcloud-my.sharepoint.com/:b:/g/personal/mgaytan_ucsd_edu/EfPy3AQDwvZAhkPqnaAPqroB2bOIaasSeq7kHPiNtTD9ZQ?e=4xdd4g
CITI "Good Clinical Practice" Completion Certificate *

Cancel of
CITI "Good Clinical Practice" completion date

Month Day Year
Note:

A Biomedical Research certificate is not required and cannot be used in lieu of the CITI "GCP" Certificate.

We require the completion certificate and not the score reference guide in order to grant clinic access.
What is your UC Health Badge Number *
Badge number is located in the back of your badge, in the bottom right

-- Clinical Lab Access Section
Clinic Lab Access:

Complete the following three courses here UC Learning Center :
1. Biosafety: Bloodborne Pathogens Training and Annual Refresher
2. Annual Laboratory Hazards Training
3. UC Laboratory Safety Fundamentals
Example Certificates: https://ucsdcloud-my.sharepoint.com/:f:/g/personal/mgaytan_ucsd_edu/EjlUBdjoavpFihm2skWdBp8BynDBLBK9fGIpRJN43ZWZ0w?e=y9iyCQ
Biosafety: Bloodborne Pathogens Trainings and Annual Refresher *

Cancel of
Biosafety: Bloodborne Pathogens Trainings and Annual Refresher completion date

Month Day Year
Date
Annual Laboratory Hazards Training *

Cancel of
Annual Laboratory Hazards Training completion date

Month Day Year
Date
UC Laboratory Safety Fundamentals *

Cancel of
UC Laboratory Safety Fundamentals completion date

Month Day Year
Date

-- Shipping Authorization Section
Shipping Authorization:

Complete the following course here UC Learning Center. You must also complete all courses necessary for Clinic and Lab access.
1. Shipping Biological Substances and Dry Ice
Certificate Example: https://ucsdcloud-my.sharepoint.com/:b:/g/personal/mgaytan_ucsd_edu/ES_HhjC6ZVZFpNYiUenaf1AB7Z91u5HLDoNnlEoi2oFf8g?e=zkdSwm
Shipping Biological Substances and Dry Ice *

Cancel of
Shipping Biological Substances and Dry Ice completion date

Month Day Year
Date
Note:

Shipping Authorization is not required, but if completed please submit a copy of the certificate.