CRA Guide
CRA Guide
CRA Guide
Academy of Clinical Research Professionals | 500 Montgomery St., Suite 800 | Alexandria, VA 22314 | www.acrpnet.org
CRA
CertifiCation Guide
Academy of Clinical Research Professionals 500 Montgomery St., Suite 800 Alexandria, VA 22314 www.acrpnet.org
Before you begin the Certification application process, be sure to: 1. Read the entire CRA Certification Guide. The CRA Certification Guide contains all the information you need to know about the exam, so please be sure to read it in full. You are required to attest to having read this information when submitting an exam application. 2. Verify Your Membership Status In order to take advantage of the reduced member rate you must be an active member before beginning the application process. Log in to acrpnet.org to verify your member status. If you want to join before applying for your exam, join online at acrpnet.org. Once you join, logout of acrpnet.org, log back in, and begin the application process. If you do not wish to become an ACRP member, and do not wish to take advantage of the discounted member rate, proceed with the application process. 3. Have All Application Documentation Ready All applications require you to submit supporting documentation in order for your application to be considered. Documentation required for CCRA applicants includes: CV or resume Job Description Note: File sizes must be under 5 megabytes for online applications. 4. Submit Your Application Once Please submit your application either online or via a printable application form (not both, to avoid duplicate charges). All required elements (application, supporting documentation, and full payment) must be submitted together at the same time. 5. After You Submit Your Application You will receive an automatic email confirmation for applications submitted online. Please allow up to 10 business days for mailed or faxed applications. All applications undergo a thorough review process. Please allow up to 3 weeks for your eligibility email notification. To ensure you receive your notification, we recommend you add acrpnet.org to your safe senders list (contact your IT department for instructions).
Page|2v.10/11
TableofContents
Topic
QuickReferences GeneralInformation WhatisCertification? TopTenReasonstoBecomeCertified AbouttheAcademyofClinicalResearchProfessionals EligibilityandApplicationfortheCRASMProgram CertificationEligibilityRequirements ClinicalResearchEducationPrograms EssentialDuties ApplicationInstructions Fees EligibilityReview IneligibilityDecisionAppealsProcess ConfirmationofEligibilityandTestingInformation WithdrawalofApplication AbouttheCRASMExam WrittenExam Language DetailedContentOutline(DCO) ExamScores PreparingfortheCRASMExam StudyText FurtherStudyTips StepstoPreparingfortheCRASMExam ExamSchedulingandTestingProcedures ReschedulingExam Emergencies(Rescheduling/Cancellations) TransfertoNextWindow Reactivation Cancellations Emergencies(Documenting) Refunds TestCenterSelection
Page
5 7 7 7 8 9 9 10 10 11 12 13 13 14 14 15 15 15 15 20 21 21 22 23 24 24 24 25 25 26 26 27 27
TableofContents(continued)
Page|3v.10/11
Topic
ServicesforPeoplewithDisabilities ExamSchedulingandAdmissionDetails ExamSecurity TestTakingStrategies ExamResults DuplicateCertificates MaintenanceofCertification RevocationofCertification HowareCertificationExamsDeveloped? ReliabilityMeasurements FrequentlyAskedQuestions NonDiscriminationPolicy Confidentiality VerificationofCredentials CertificationMarkUse DisciplineandComplaintsPolicy Appendix1SampleCV Appendix2SpecialAccommodationsRequestForm Appendix3ExamTransferRequestForm Appendix4EmergencyCancellationForm Appendix5DuplicateCertificateRequestForm
Page
27 28 29 29 30 30 30 32 32 34 34 37 37 37 37 37 38 39 40 41 42
Page|4v.10/11
Exam Registration Questions Exam Application Received? Didnt Receive Notification of Eligibility What is my Prometric Testing ID Number? How Can I Locate a Test Site? How Much Are Exam Fees? ACRP Member Services The Academy The Academy [email protected] [email protected] [email protected]
www.prometric.com/ACRP www.acrpnet.org
Exam Rescheduling (within SAME testing window) Exam Rescheduling greater than 29 days prior to exam Exam Rescheduling 16- 29 days prior to exam Exam Rescheduling 5-15 days prior to exam No rescheduling permitted less than 5 days prior to exam date Exam Transfers/Cancellations Exam Transfers/Cancellation greater than 29 days prior to exam Both: Prometric FIRST to cancel appointment, then notify the Academy via email Both: Prometric FIRST to pay $25, then notify the Academy via email Both: Prometric FIRST to pay $50, then notify the Academy via email no refunds permitted < 5 days prior to scheduled exam 800-853-6769 [email protected] 800-853-6769 [email protected] Prometric 800-853-6769
800-853-6769
800-853-6769
The Academy
Exam Transfers/Cancellation 5-15 days prior to scheduled exam (no cancellations permitted less than 5 days prior)
800-853-6769 [email protected]
Page|5v.10/11
Change of Contact Information General Contact Information Prometric Member Services To report issues with your Prometric experience Academy of Clinical Research Professionals (the Academy)
Prometric Prometric
800-481-6525 800-853-6769
Certification Department
500 Montgomery Str, Suite 800 Alexandria VA 22314-1560 Phone: 703-254-8100 Fax: 703-254-8101 Email: [email protected]
The Academy of Clinical Research Professionals (the Academy) would like to congratulate you on your decision to pursue certification in your chosen field of work. As a professional in clinical research, you deserve to be recognised and appreciated for what you do. And like most professionals, you want to become better at it. You look for opportunities for on-going meaningful professional development, and practical ways to evaluate your own work that will help you develop as a professional. This is one reason the Academys CCRA credential was created.
What is Certification?
Certification is a voluntary process to recognize individuals for meeting professional standards set by an impartial thirdparty. The Academy Certification is the formal recognition of clinical research professionals who have met eligibility requirements and demonstrated proficiency of specific knowledge and jobrelated skills by passing a standardized exam. Academy Certification programs are the only ones in clinical research accredited by the National Commission for Certifying Agencies (NCCA). NCCA sets independent standards for the development and operation of certification programs. This assures the validity and credibility of the process; that the process reflects current, jobspecific practice and fairness to candidates. For more information on the NCCA, please visit www.credentialingexcellence.org/ncca.
1. Credibility. Academy Certification serves as an impartial, thirdparty endorsement of your knowledge and experience against international standards in clinical research. It adds to your credibility as a clinical researcher and sets you apart from other professionals. 2. Improves career opportunities and advancement. Academy Certification can give you an advantage when being considered for a promotion or other career opportunities. Certification through the Academy clearly identifies you as an employee who has demonstrated proficiency of internationally accepted clinical research principles, techniques, and application of best practices onthejob. 3. Increases onthejob responsibilities. Academy Certification is a clear indicator of your willingness to invest in your own professional development. Certified professionals are aware of the constantly changing environment around their profession and possess the desire to anticipate and respond to change. 4. Enhances skills and knowledge. Achieving Certification through the Academy requires training, studying, and keeping uptodate with changes in the profession. Certification showcases your individual mastery by confirming proficiency in the field. Academy Certification also requires Maintenance of Certification every two years, to ensure you stay informed and continue to develop as a clinical research professional. 5. Earnings potential. Many clinical research professionals who have become Academy certificants experience salary and wage increases and/or bonuses based on their Certification status. In addition, Academy certificants are in high demand and aggressively recruited. 6. Demonstrates your engagement. Earning Certification through the Academy shows your peers, supervisors and, in turn, trial subjects, your commitment to your chosen career and the clinical research profession atlarge, as well as your ability to perform to set standards.
7. Strengthens the professions image. The Academys Certification Program seeks to grow, promote, and develop certified professionals, who can serve as role models for Good Clinical Practice (GCP) in the clinical research field.
Page|7v.10/11
8. Accomplishment. The Academys Certification is a reflection of personal achievement because you have validated your skill set, specific to the job role you perform, by meeting internationally recognized standards set forth via International Conference on Harmonization (ICH) Guidelines. 9. Builds selfesteem. Certification through the Academy is a step toward defining yourself beyond a job description or academic degree while gaining a sense of personal satisfaction. 10. Recognition. As an Academy certificant, you can expect increased acknowledgement from your peers for taking that extra step in your professional career.
Page|8v.10/11
Eligibility Requirements
ACRAisaprofessionalwho,regardlessofjobtitle,supervises,monitors,andsupportsthe administrationandprogressofaclinicaltrialonbehalfofasponsor.Thesponsor,whoseintentisthe researchofpharmaceuticals,biologics,ordevices,mayemploytheseindividualseitherdirectlyor indirectlyviaContractResearchOrganizations(CROs)orasindependentconsultantsorcontractors.The CRAmustbeindependentoftheinvestigativestaffconductingtheresearchatthesiteorinstitution.
CCRA Eligibility Requirements Work Experience Education Performing the Essential Duties Bachelors degree OR 3,000 hours Masters degree OR Registered Nurse (RN) Required Documentation of Performance of Essential Duties Detailed CV /Resume AND Job Description submitted WITH application
Option 1
Option 2
Bachelors degree OR Masters degree OR Registered Nurse (RN) AND Completion of a clinical research education program* of at least 216 hours AND accredited Associates degree
1,500 hours
Detailed CV/Resume AND Job Description AND Certificate of Completion from school submitted WITH application Detailed CV /Resume AND Job Description submitted WITH application Detailed CV/Resume AND Job Description AND Certificate of Completion from school submitted WITH application
Option 3
4,500 hours
Option 4
Associated degree AND Completion of a clinical research education program* of at least 216 hours AND accredited
3,000 hours
Option 3
Other, such as LPN, LVN, Medical Assistant, Lab Technician OR High School diploma
6,000 hours
Detailed CV/Resume AND Job Description submitted WITH application Detailed CV/Resume AND Job Description AND Certificate of Completion from school submitted WITH application
Option 4
Other, such as LPN, LVN, Medical Assistant, Lab Technician OR High School diploma AND Completion of a clinical research education program* of at least 216 hours AND accredited
4,500 hours
Page|9v.10/11
A list of recognized accrediting agencies on the following websites: Council on Higher Education Accreditation (CHEA): http://www.chea.org/search/default.asp Government (USDE): http://www.ed.gov/students/prep/college/diplomamills/index.html?src=rt
If an applicant submits the application using an educational program as a substitute for 1,500 hours of CRA work experience, then the following information must be included on the applicants CV (See Appendix 1 for Sample CV) and a certificate of completion must also be submitted: Name of School City, Country in which the school is located Program Title Name of Organization that accredits the institution providing the program Dates Attended (From-To)
Essential Duties:
As defined by the Academy, and determined through ACRPs 2010 Job Analysis Survey, Clinical Research Associates who are eligible for CRA Certification must document performance of each of the following Essential Duties during the dates of employment listed on the application: Verify that the research site personnel, including the investigators, are conducting the study according to the clinical protocol, Good Clinical Practices, and regulatory requirements; Ensure reporting of adverse events from research site staff to the sponsor and the IRB/IEC; Verify that the data in the Case Report Forms (CRFs) are in agreement with the source documents (source data verification); Review accuracy and completeness of site records (site study file, query resolution, and other data collection tools); Verify Investigational Product accountability; Complete reporting and ensure management and resolution of all these activities (e.g., visit reports, trial management tracking system); Conduct routine monitoring visits on behalf of the clinical trial sponsor.
Applicants must submit a detailed resume or CV (see Appendix 1 for sample CV) and a job description with the exam application. This must include a description of the candidates CRA job functions and specific employment dates. Do not include a list of study participation on your CV.
Page|10v.10/11
Application Instructions
Applicants must complete an application form in order to be considered for eligibility to take the Written Exam. We encourage all candidates to use the online application that can be found on the ACRP website at http://www.acrpnet.org/CRACertification. Applicants who must pay by check will need to complete a printable application and submit a hard-copy with their payment. If completing the printable application, make sure the application is received by the Academy by the deadline to avoid the late fee. The exam dates and application receipt deadlines (NOT postmark deadlines) are as follows:
Exam Dates
Application Deadlines for Receipt of Application with Late Fee January 24-February 6, 2012
To apply for an exam, an applicant must submit either the online or printable exam application along with a copy of a detailed resume or CV that shows job functions and specific employment dates, a job description, and the appropriate fees by the application receipt deadline. Online and printable applications can be found at http://www.acrpnet.org/CRACertification
Payment Method Documents Required to be Submitted WITH Application 1. CV/Resume 2. Job Description 3. Educational Program Certificate (if required) Documents should be uploaded as part of application or faxed CV/Resume Job Description Educational Program Certificate (if required) Documents should be included with mailed application CV/Resume Job Description Educational Program Certificate (if required) Documents should be included with mailed application By Deadline Date On-line Submission Complete and All Documents UPLOADED
Application Method
Credit Card
1. 2. 3. 1. 2. 3.
Credit Card
VERY IMPORTANT: Incomplete applications, or applications submitted without the correct fee, will not be processed. Submission of your application constitutes agreement that you have read, understood, and have agreed to abide by the ACRP/APPI Unified Code of Ethics. An email confirmation is automatically sent once payment is processed. Applicants will also be sent an email that confirms that the application was received by the Academy. PLEASE NOTE: These
Page|11v.10/11
confirmations do not confer eligibility. A separate notification will be sent regarding an eligibility decision. Please take any necessary steps to prevent filtering of ACRP emails. For those submitting the printable application, for the applicants protection, it is highly recommended that the application be mailed to the Academy via certified mail, express parcel service, or a traceable courier to ensure receipt by the application receipt deadline. Faxed applications will be accepted if you are paying by credit card. Keep your fax confirmation for your records.
Fees
Only applications received with full payment and all required supporting documentation will be processed. To activate the ACRP member rate, the applicant must join/re-join ACRP before applying for the exam. To compare costs, feel free to use the cost calculator on the ACRP website at: view membership rates, visit the membership section of the website at: http://www.acrpnet.org/popups/CRA-fee-calculator.html Applications submitted after the regular deadline, during the Extended Deadline period, incur an additional late fee. CCRA Application and Exam Fees Standard Fee Regular Deadline Application Fee Non refundable Exam Fee Late Fee Non refundable TOTAL AMOUNT DUE at Application
$115
$115
$115
$115
$583
$383
$583
$383
--
---
$150
$150
$698
$498
$848
$648
All exam fees include a non-refundable $115 application fee regardless of eligibility status or cancellation. The late fee is also non-refundable. All fees must be paid in full by check or credit card (American Express, VISA, or MasterCard). Corporate checks must reference each applicants name.
Page|12v.10/11
Eligibility Review
Applicants are required to sign a disclosure statement attesting to the accuracy of the information provided as part of the application process. By submitting an application, applicants consent to and authorize the Academy to verify the candidates academic and employment records. It is the candidates responsibility to submit all relevant documents at the time of application. Employers must be listed on the candidates application form. The Academy has the right to verify qualifications. By submitting an application, applicants consent to and authorize the Academy to verify the applicants academic and employment records. The Academy does reserve the right to request backup documentation to substantiate the reported information at any time. The Eligibility Review process includes determining completeness of the application and determining whether or not the applicant meets the eligibility criteria for the exam. This process begins with one week of confirmation of receipt of the application. It can take up to one (1) month to review an application. It is not unusual for an applicant to receive a request for additional and/or clarifying information from an Eligibility Reviewer. These requests will come via email. Applicants will have seven (7) calendar days to respond to the request. Applicants who do not respond to the request for additional or clarifying information will automatically have their applications determined ineligible. INCOMPLETE and therefore ineligible applications will be refunded the exam fee ONLY and candidates will need to re-apply to the program and pay all fees. Incomplete applications will not be returned. If an applicant is determined to be ELIGIBLE, the candidate will be notified via email two to three weeks after receipt of the complete application, with further instructions as to how to schedule his/her exam appointment. If an applicant is determined to be INELIGIBLE during initial review, the application is automatically reviewed by a second reviewer. If the second reviewer ALSO determines the applicant to be ineligible, the application is automatically sent to the Director of Certification for a third review. Applicants are notified via email at each step of the review with an explanation of the deficiency identified. If, after the three levels of review, the applicant is still determined to be Ineligible, the applicant can choose to appeal to the Academy Board of Trustees. However, after the third level of review by the Director of Certification, applicants can no longer submit NEW documents to overturn an eligibility decision. Applicants found to be INELIGIBLE and who do not initiate the Appeals Process will automatically be refunded the Exam Fee ONLY within a month.
Page|13v.10/11
In the written notice of appeal, the applicant shall submit additional, written, factual documentation to support his/her appeal with an explanation of why he or she believes the reviewer erred in his/her decision. No new documents pertaining to the applicants eligibility shall be accepted during the appeals process. The applicant shall bear the burden of proving the denial of eligibility was based on erroneous factual determination of the reviewer. The Academy Board of Trustees will review the candidates application and accompanying documents and the appeal letter. The applicant will be notified via hard-copy mail of the decision of the Academy Board of Trustees and the decision shall be final.
For further details on the procedures for scheduling exam appointment and the test taking experience, please see page 24.
Withdrawal of Application
Once a candidate submits an application for certification, it cannot be withdrawn. Candidates who wish to discontinue the certification process may submit a request via email to [email protected] to obtain a refund of the Exam Fee only. If a candidate submits such a request, AND the candidate has received an Eligibility ID, the ID number will be invalidated.
Page|14v.10/11
Written Exam
The Certified Clinical Research Associate (CCRA) Examination is designed as a practice-based exam for individuals involved in the performance of the essential duties of a clinical research Associate to assess proficiency of the five (5) core knowledge areas: 1. 2. 3. 4. 5. Investigational Product Management Protocol Safety Trial Management Trial Oversight
The examination consists of 125 multiple- choice questions. (25 of these questions are pre-test items and do not affect a candidates score.) Candidates are presented with a question and are asked to choose the single BEST answer from the four options provided. Only one answer is correct. Questions test recall, application, and analysis. Some questions use hypothetical scenarios. The exam content is based on a process of expert peer review, performed by the Global CCRA Exam Committee. There are no trick questions on the examination. There is no penalty for guessing. Each candidate is allowed a maximum of three (3) hours to complete the exam.
Language
The CRA Certification Exam is provided in English. Exam candidates may bring a hard-copy English-German / Spanish / Chinese / Hindi / etc., translation dictionary to the exam. Electronic dictionaries are not permitted. The dictionary will be inspected by the proctor prior to and after the exam is completed. Any attempt to compromise the exam will be grounds for immediate dismissal from the site, invalidation of the exam score, and possible legal action. Use of dictionaries is discouraged as this uses valuable testing time.
As defined by the 2010 ACRP Job Analysis Survey, a Certified Clinical Research Associate (CCRA) shall have proficiency in the following areas of clinical research:
Page|15v.10/11
Maintain accountability of investigational product Retrieve investigational product and calculate subject compliance Maintain randomization and emergency codes of investigational product dispensing
Using knowledge of: Investigational product (e.g., package insert, report of prior investigations, Investigator's Brochure) Investigational product inventory Investigational product accountability Investigational product storage Packaging and labeling Product Development Supplemental/ rescue/ comparator product Investigational product compliance (e.g., protocol, standard operation procedures, local governance) Accountability records
II.
Protocol
Review product development plan Identify study objective/design Develop the protocol (e.g., inclusion/exclusion criteria, procedures, schedule of events, safety and efficacy parameters) Evaluate protocol for scientific soundness Evaluate protocol for feasibility Evaluate congruence of data collection tools (e.g., case report form (CRF), electronic data capture (EDC) with the study protocol Verify the eligibility of potential trial subjects Contribute to protocol development Coordinate protocol approval process Review protocol for feasibility Review protocol during Investigators meeting Execute study per protocol Recommend and Implement protocol amendments
Using knowledge of: Protocol development Protocol submission and approval procedures Clinical trial phase Study design characteristics (e.g., double-blind, crossover, randomized) Study objective Description of procedures Amendment submission and approval procedures Inclusion/exclusion criteria Statistical plan III. Safety Assess safety during trial participation Minimize potential risks to subject safety Oversee safety risks (e.g., clinical holds, product recalls) Ensure adverse events reporting is documented (e.g., serious, severe, moderate, mild, expected, unexpected) Ensure reasons for subject discontinuation are documented (i.e., causes, contact efforts) Conduct study-related procedures and monitor the safety of the trial subjects and investigational staff
Page|16v.10/11
Manage and motivate the investigational staff and other disciplines involved, and take measures to minimize any potential risks Review common laboratory values and alerts Identify expected or unexpected results associated with investigational products Maintain follow-up to determine resolution of adverse event Conduct safety monitoring/reporting activities
Using knowledge of: Investigators Brochure Safety monitoring Safety and clinical databases Subject safety issues (e.g., toxicity, significant lab values) Vulnerable subject populations Adverse events reporting Serious adverse events reporting Safety reporting requirements
IV.
Trial Management
Verify investigator/site feasibility Develop timelines for conducting and completing the clinical trial Prepare and conduct initiation activities Ensure appropriate training of the investigational staff Develop a recruitment strategy and study management plan Follow a recruitment strategy and study management plan Review, clarify, and obtain data changes from sites Schedule and coordinate pre-study site visit Identify minimum regulatory document requirements for site trial master file (e.g., countryspecific regulatory documents) Ensure IRB/IEC review/approval of study and study documents Facilitate site budget/contract approval process Develop Case Report Forms (e.g., CRFs, eCRFs) Develop CRF completion guidelines Develop monitoring guidelines/plans Develop project tools Submit documents to regulatory authorities Document and communicate site visit findings Ensure clinical trial registry requirements are met Ensure timely review of study data (e.g., laboratory results, x-rays) Maintain current vendor credentials (e.g., lab certification/licensure and normal ranges) Prepare and conduct interim monitoring visit(s) Prepare and conduct close-out monitoring visit(s) Reconcile payments to sites per contract Document protocol deviations/violations Reconcile safety and clinical databases Conduct co-monitoring/training visits Perform remote monitoring activities Train site personnel on Sponsor/CRO and regulatory requirements for study conduct (e.g., protocol procedures, EDC) Transmit CRFs to Data Management Review CRF queries from Data Management Coordinate study monitoring visits Draft study specific tools (e.g., source document, tracking tools)
Page|17v.10/11
Implement corrective actions plans Maintain trial master file (e.g., regulatory binder) Manage study supplies (e.g., lab kits, case report forms) Comply with subject privacy regulations Manage study issues
Using knowledge of: Site Activities Contract budget negotiations and approval process Project feasibility Project timelines Monitoring guidelines/plan and tools Study project tools Staff qualifications Staff roles and responsibilities Data management activities Plan for staff oversight Investigator qualifications/ site selection (e.g., therapeutic area, education, experience) Disposition of unused study-related materials (e.g., CRF at end of study, destruction of lab kits) Equipment and supplies (e.g., x-ray, computer, lab kits) and storage Study management plan (e.g., timelines, data management) Communication documentation (e.g., telephone, email) Pre-study site visit Investigator's meeting Site initiation Monitoring visit Close-out visit Site monitoring visit log Site signature log Delegation listing Trial master file (e.g., site, sponsor) Data management plan Data query resolution Electronic data (e.g., electronic health records, electronic case report forms) Recruitment plans/strategies Subject compliance Subject visit logistics Protection of human subjects Subject selection, screening, and recruitment Subject retention Subject discontinuation Subject reimbursement Good Clinical Practice Regulatory documents Record retention Subject privacy regulations Case Report Form Visit reports (e.g., initiation, close-out) Final report Progress reports
Page|18v.10/11
Essential documentation, subject related and non-subject related (e.g., past medical records, lab reports, protocol, IRB approvals) Informed consent Procedure manuals Source documentation Protocol deviations Indemnification/insurance Clinical trial registry
V.
Trial Oversight
Ensure consistency between the sites standard operation procedures (SOPs) and the study requirements Ensure investigator/site protocol compliance Facilitate investigator/site corrective actions Oversee vendors (e.g. Contract Research Organizations (CROs)) Ensure compliance with electronic data requirements (e.g., electronic health records, eCRF) Ensure adequate site management Prepare the study site for audits and inspections Respond to or facilitate response to audit/inspection findings Ensure proper collection, processing, and shipment of specimens (e.g., centrifuge, preparation of slides, freezing, refrigeration) Ensure proper adverse event reporting by the investigator Escalate problems to appropriate in-house management Investigate potential fraud and misconduct Report potential fraud and misconduct Ensure follow-up medical care for study subjects is documented, as applicable Ensure adequate consent and documentation Ensure staff, facility, and equipment availability throughout the study Ensure compliance with study requirements and regulations Prepare for audits, inspections, and follow up Ensure access to source data by authorized parties, in accordance with ICH-GCP, and protect confidentiality by limiting unauthorized access Ensure that IRB/IEC documentation is adequate and that details of the IRB/IEC composition are on file
Using knowledge of: Issues management (e.g., escalation) Audit preparation Regulatory standards Audit documents Project monitoring guidelines Project investigator supervision requirements
Page|19v.10/11
Exam Scores
Prometric, the Academys professional testing partner, scores all exams. One point is granted for each correct answer. There is no penalty assessed for an incorrect answer; points are scored only for correct answers. The number of questions answered correctly is a candidates raw score. The "Total Scaled Score" will determine whether a candidate has passed the exam. This scaled score is statistically derived from the candidate's raw score and can range from 200 800. The passing scaled score for the CCRA exam 600. The passing score reflects the minimum amount of knowledge a committee of experts has determined to be appropriate for Certification, according to accepted test development guidelines. A criterion-referenced, standard-setting procedure and expert judgment are used to identify the passing point. The Academy uses the widely accepted Modified Angoff method. A candidate's ability to pass the exam depends on the amount of knowledge he or she demonstrates, not on the performance of other individuals taking the exam. The reason for calculating scaled scores is that different forms or versions of the exam may vary in difficulty. As new versions of the exams are introduced, a certain number of questions in each content area are replaced by new questions. These changes may cause one version of the exam to be slightly easier or harder than another version. To adjust for these differences in difficulty, a statistical procedure called "equating" is used. The goal of equating is to ensure fairness to all candidates. In the equating process, the minimum raw score (number of correctly answered questions) required to equal the passing scaled score is statistically adjusted (or equated). For instance, if the exam is determined to be more difficult than the base form of the exam, then the minimum raw score required to pass will be slightly lower than the passing scaled score. If the exam is a bit easier, then the passing raw score will be slightly higher than the passing scaled score. Equating helps ensure that the passing scaled score represents the same level of knowledge, regardless of which version of the exam a candidate takes. A candidate scoring below the minimum scaled score has not been successful on the exam and cannot be certified. The exam is not scored on a curve. There are not a predetermined number of candidates permitted to pass. Your score does not depend on the other candidates who are testing with you that day. Note: The passing point set for the exam cannot be appealed. To score one point below the passing point is to be unsuccessful on the exam; to score at the passing point or higher is to pass the exam. A score higher than the passing point is not an indication of a higher proficiency in the subject matter. Specific questions on the exam, answers to exam questions will not be discussed or released. Due to the security of the item bank and because exam questions can be used on various exams, exam questions will not be discussed with candidates and candidates may not have access to the exam or their answers.
Page|20v.10/11
Study Texts
In order to prepare for the exam, all candidates should review and be familiar with the relevant regulations from: ICH Guidelines (E2A, E6, E8 and E9) Declaration of Helsinki* (latest version)
The most current copy of the ICH Guidelines and other regulatory materials may be found on the following websites: Declaration of Helsinki: http://www.wma.net/en/20activities/10ethics/10helsinki/index.html ICH Guidelines: http://www.ich.org
*Note of clarification on paragraph 29 of the WMA Declaration of Helsinki. The WMA is concerned that paragraph 29 of the revised Declaration of Helsinki (October 2000) has led to diverse interpretations and possible confusion. It hereby reaffirms its position that extreme care must be taken in making use of a placebo-controlled trial and that in general this methodology should only be used in the absence of existing proven therapy. However, a placebo-controlled trial may be ethically acceptable, even if proven therapy is available, under the following circumstances:
Page|21v.10/11
Where for compelling and scientifically sound methodological reasons its use is necessary to determine the efficacy or safety of a prophylactic, diagnostic, or therapeutic method; or Where a prophylactic, diagnostic, or therapeutic method is being investigated for a minor condition and the patients who receive placebo will not be subject to any additional risk of serious or irreversible harm.
All other provisions of the Declaration of Helsinki must be adhered to, especially the need for appropriate ethical and scientific review.
Page|22v.10/11
STEP 5: Choose the materials that are right for YOUR study plan. Choose a mentor or colleague who has more experience in the areas in which you are less familiar and ask them to review concepts with you. As you perform your daily responsibilities, think about the underlying principles that dictate you take a particular course of action. STEP 6: Stick to your study groups plan: Pick a regular night and show up on time. Each of you has the same goal and everyone has something to offer. Sharing reading and exchanging book notes is a great way to lighten the load. Study groups foster friendships and provide an incentive to stay focused on your collective goal. Complete, dont compete. STEP 7: Dont Panic! Follow the excellent pre-exam advice that the Academy provides and come to the exam well-rested and prepared. Approximately 80% of candidates are successful on their first exam attempt.
Page|23v.10/11
Prometric Fees
No charge
Method
Online or via phone
$25
$50 Not permitted full Exam fee forfeited See Policy below All fees forfeited
Emergencies
If a candidate will be unable to keep their exam appointment due to an emergency situation that arises within five (5) days prior to their exam date, the candidate is required to submit an Emergency Cancellation Form and official documentation to the Academy at [email protected] documenting the emergency. This information should be received by the candidates scheduled exam date or no more than seven (7) days after the scheduled exam date. The following situations will be considered: Emergency room visit or hospitalization Severe medical condition requiring hospitalization Death of an immediate family member (spouse, child/dependent, parent, grandparent, sibling) Jury duty Call to active military duty
Page|24v.10/11
Reactivation Form
Once a candidate has indicated his/her interest in transferring to the next testing window, he or she must submit a Reactivation Form to signal his/her intent to test. The Reactivation Form must be submitted by the regular deadline for the next testing window. Reactivation Forms are emailed at the start of the next Exam application period and are addressed to confirmed Transfer candidates only. If a candidate who has transferred his/her eligibility does not submit a Reactivation Form by the regular deadline, the candidate will forfeit all fees.
Page|25v.10/11
Cancellations
Cancelling your exam appointment (test center location, date, or time) is permitted by Prometric up to 5 days before your scheduled day by contacting Prometric directly at 800-853-6769. There may be fees associated with appointment cancellations.
Prometric Fees
No charge
Method
Online or via phone
$25
$50 Not permitted full Exam fee forfeited See Policy below All fees forfeited
Note: See Refunds section below. The Academy does not refund fees for exam cancellation requests received less than 5 days prior to the scheduled exam. To cancel an exam appointment it is mandatory that the candidate FIRST contact Prometric directly at 800-853-6769 and then contact the Academy at [email protected]. Only the candidate may request a cancellation, regardless of whether the exam fee was paid by the candidate or another party. If the candidate has not yet scheduled the exam appointment with Prometric, it is mandatory that the candidate submit an Exam Transfer Request Form or request a refund by the end of the Exam Window for which the candidate originally applied. Exam Fees are non-refundable for requests received after the close of the Exam Window.
Emergencies
If a candidate will be unable to keep their exam appointment due to an emergency situation that arises within five (5) days prior to their exam date, the candidate is required to submit an Emergency Cancellation Form and official documentation to the Academy at [email protected] documenting the emergency. This information should be received by the candidates scheduled exam date or no more than seven (7) days after the scheduled exam date. The following situations will be considered: Emergency room visit or hospitalization Severe medical condition requiring hospitalization Death of an immediate family member (spouse, child/dependent, parent, grandparent, sibling) Jury duty Call to active military duty
Page|26v.10/11
Refunds
If a candidate must cancel an exam, the ONLY portion of the total amount submitted that will be refunded is the Exam Fee provided that the request for cancellation is received at least 5 calendar days prior to a scheduled exam appointment. Cancellation requests received after that time will not be refunded. No refunds are available to candidates who do not attend the exam. Refund requests will only be accepted if made by the candidate. Applications who do not meet the eligibility requirements for the exam (are ineligible), or who are ineligible due to an incomplete application, will receive a refund of the exam fee ONLY. Refund requests can only be made by the candidate. The refund will be sent to the party who initially paid for the exam. If payment was made by credit card, that card will receive the credit. If the payment was made by check, the Academy will mail a refund check to the original payer.
To request a reasonable accommodation, check the appropriate box on the application. See Appendix 2 of this guide to obtain the Special Accommodations Form. A link to the Special Accommodations form is also available on both the online and printable applications. Complete and submit with your application.
Page|27v.10/11
Page|28v.10/11
Exam Security
Exam content will be transported via encrypted electronic file to each exam site to ensure the security of the exam questions. Computer-based testing allows for different versions of the exam to be offered and for changes in the sequence of questions to reduce the likelihood of misconduct, and enhances the validity and integrity of the exam. Each exam will be delivered via individual video-monitored testing carrels -- both for better privacy while the candidate is taking the exam and to prevent unethical behavior. Examinees will be presented with Prometric Testing Center Regulations upon arrival at the test site. It is imperative to read the information provided, because those who violate security will not have their exams scored or processed, and will be required to leave the room immediately. To view regulations in advance, visit http://www.prometric.com/TestTakers/FAQs/default.htm. Removing or attempting to remove exam material or content from the testing center will result in severe criminal and civil legal consequences.
Page|29v.10/11
Exam Results
Computer-based testing provides participants with preliminary results immediately, with official confirmation of results following within 30 days. On-site notices are preliminary and candidates are not yet considered certified until official notification is received from the Academy. Candidates who pass the exam will be sent an official notice of Certification, a certificate, a CCRA pin, and Maintenance of Certification information. Candidates who do not pass the exam are advised to review the content area scores and use this information to assist them in preparing for future exams. Final exam results will NOT be given out over the telephone or by fax, nor will results be sent to employers, schools, other individuals, or organizations under any circumstances. Candidates who pass the exam will be added to the Academy Certification registry unless they opt out. The Registry can be access at http://www.avectraacrp.com/eWeb/DynamicPage.aspx?Site=ACRP&WebKey=078ec803-bceb4265-9ca4-81780725fa6e
Duplicate Certificates
There is a $25 charge for a duplicate certificate if the request is made more than three months after the exam. Requests may be made in writing by completing the Duplicate Certificate Form to ACADEMY at [email protected].
Page|30v.10/11
Requirements: To maintain Certification successfully, CCRA certificants must: 1. Satisfy the requirements of either Option 1 or Option 2 listed below. 2. Document the hours/points on the Maintenance application (online or printable form). 3. Submit completed application together with appropriate payment by expiration date*. *Incomplete submissions will be charged the late fee if not rectified by the expiration date. Option 1 Contact Hours Only: Maintenance of Certification by continuing education requires the completion of 24 documented continuing education contact hours within the appropriate timeframe, with at least 12 of those hours being in clinical research topics. The remaining hours claimed to make up the 24 hour requirement must be from healthcare related courses (therapeutic topics). OR Option 2 Contact Hours and Continuing Involvement: Maintenance of Certification may also be achieved by the completion of a total of 24 documented points; a maximum of 12 continuing involvement points (see chart below) and 12+ continuing education points (a minimum of 8 points (for this option only) must be in clinical research topics)*.
CCRA Maintenance Requirements 24 points Total Needed Activity Continuing Education Clinical Research Topics Continuing Education Therapeutic Topics Continuing Involvement Item Authoring a journal article on Clinical Research Topics Continuing Involvement Item Preparing/presenting a 1-3 hour presentation on Clinical Research Topics Continuing Involvement Item Authoring/presenting a half-day workshop on Clinical Research Topics Continuing Involvement Item Authoring/presenting a one-day workshop on Clinical Research Topics Number of Points Each 1 point for each hour of instruction 1 point for each hour of instruction Maximum Points Allowed in Category 24 12
12
12
12
Page|31v.10/11
Revocation of Certification
The Academy may revoke Certification, or take other disciplinary or legal action, in the case of falsification or the provision of misleading or incomplete information in the CV or statement of experience. ACRP may also revoke Certification, or take other disciplinary or legal action, in the event that an individual is in violation of the ACRP/APPI Uniform Code of Ethics and Professional Conduct or has regulatory or professional restrictions placed on his or her clinical research practice or professional license. ACRP will adhere to due process principles. If a certificant is notified of revocation, he or she will also be notified of the appeal process. Copies of the Discipline and Complaints Policy and Appeals Policy may be requested by contacting the ACRP office in writing.
Page|32v.10/11
Once a draft question is approved by the Exam Committee, it then becomes a pre-test question. All questions are pre-tested before they are counted toward a candidates score. The exams given to candidates are 125 questions long. 100 of those questions are count toward the candidates score. 25 are pre-test questions. This means the Academy is collecting statistical data on the items to see if they are well constructed enough to appear on the exam as a scored item. Hundreds of candidates answer a pre-test question before it can be determined if it can be used toward a candidates score. Once enough data has been collected, analyses are performed on the item statistics in conjunction with the Academys professional test development partner to see if items have performed well enough to be used. If they have not performed well, (for example, many are choosing the wrong answer; or each of the four answers is being selected equally which indicates test-takers are guessing; or candidates who score well on the exam overall are selecting a wrong answer), then the questions is set aside for further review and re-write or possibly discarded. Only those questions that demonstrate they are fair to the test taker and identify proficiency in a candidate are used. Several diverse groups of CRA volunteers are used to write the questions, review the questions, select questions to be pre-tested and to select and review questions that actually appear on the exam. The Academy follows a process that meets international standards for test development and works with a highly-regarded testing partner. To date, more than 24,000 clinical research professionals have been Certified by the Academy. On average, 80% of those who sit for an exam pass the exam.
CRA Exam
Sep-11 Took Exam Total Certified Percent Passing 362 236 65.19% Mar11 282 208 73.76% Sep-10 448 325 72.54% Mar10 336 244 72.62% Sep-09 450 335 74.44% Mar09 415 298 71.81% Sep-08 501 389 77.64% Mar08 371 294 79.25%
CPI Exam
Sep-11 Took Exam Total Certified Percent Passing 42 35 83.33% Mar11 30 24 80% Sep-10 58 50 86.20% Mar10 36 28 77.78% Sep-09 54 38 70.37% Mar09 65 54 83.08% Sep-08 103 84 81.55% Mar08 63 57 90.48%
All Programs
Percent Passing 70.47% 74.97% 78.09% 75.60% 77.30% 77.35% 79.46% 82.22%
Page|33v.10/11
Reliability Measurements
After every Certification exam, the Exam Committees review the results with the assistance of Prometric, one of the testing industry's leading firms. Each item is analyzed for appropriate psychometric characteristics. Those items with poor statistical results are reviewed by the appropriate Exam Committee to ensure that they have been scored properly. Participant feedback regarding the exam and its contents is also reviewed and taken into consideration when reviewing the exam and future test items.
Page|34v.10/11
What tools does ACRP have available to help me prepare for the exams? As noted earlier in this Guide, the Detailed Content Outline (DCO) and therefore the content of the CCRA exam, has been updated for exams beginning in 2012. ACRPs Professional Development program is currently in the process of developing CRA role-specific guides to assist candidates in reviewing concepts that may be found on the exam. It will be available for purchase in January 2012. In addition, beginning in January 2012, a new Candidate Self- Assessment, which is made up of job-role specific test questions retired from previous exams will also be available for purchase. These questions are designed to be representative of those you will see on the exam and to familiarize yourself with the format of the exam, but should not be used to identify areas for additional study. For further information, please visit http://www.acrpnet.org/examprep What is the Academys Maintenance of Certification process? The Academy requires periodic Maintenance of Certification to ensure that individuals who hold a CCRA credential maintain their ongoing commitment to professional development in their selected area of practice. Through the Maintenance of Certification requirements, certificants demonstrate expansion and reinforcement of their knowledge of current practice. The Academy supports this purpose by requiring appropriate and relevant continuing education activities to enhance the professional development of certificants. The Maintenance of Certification program also serves to encourage and recognize individuals who participate in ongoing professional development. CCRAs must maintain every two (2) years from the time of original Certification. The two year Maintenance of Certification cycle is based on the frequency of change in the clinical research field. Maintenance of Certification requires the completion of 24 documented continuing education contact hours. A minimum of 12 of the 24 hours completed MUST be in clinical research topics. Effective January 1, 2010, Maintenance of Certification may also be achieved by completion of a total of 24 documented points, with a maximum of 12 points of continuing involvement activities according to the schedule below: Authoring a journal article 4 points per article 8 points maximum Preparing/presenting a 1 hour presentation 3 points per presentation 6 points maximum* Authoring/presenting a day workshop 6 points per workshop 12 points maximum* Authoring/presenting a 1 day workshop 12 points per workshop 12 points maximum*
*Points may only be claimed one time regardless of how many times the same program is presented. Continuing education contact hours must be used to complete the 24 point requirement if the full 12 points of continuing involvement are not used. If continuing involvement activities are used for maintenance, of the remaining points earned through continuing education a minimum of 8 continuing education contact hours must be in clinical research topics.
Page|35v.10/11
What records of continuing education or continuing involvement activities should I keep? Copies of certificates should not be submitted with the maintenance submission. Certificants should retain all certificates with their records in case of selection for a random verification. The Academy will request these records if needed. All continuing education activities submitted for Certification maintenance are subject to review and approval. The Academy reserves the right to request additional information and to verify any documentation, including academic records. Credit may be denied for continuing education activities that fail to meet the guidelines established in this policy. What type of contact hours can I use to maintain? The Maintenance of Certification Guide explains that acceptable courses for earning continuing education contact hours include those offered by: All state and national nursing associations; American Council on Pharmaceutical Education (ACPE); Accreditation Council for Continuing Medical Education (ACCME); and Other national healthcare-related associations (respiratory therapy, medical technician, etc.).
What are examples of unacceptable continuing education contact hours? Attendance certificates for programs that do not offer continuing education contact hours with a provider number. CPR or BLS training courses Blood pressure training courses Investigator meetings that don't offer contact hours Courses that focus on self-improvement, changes in attitude, computer skills, investments, and liberal arts
What happens if I do not maintain my Certification? Individuals who fail to properly maintain their Certification(s) will be decertified for failure to maintain by the specified deadline. You will receive a 2-week grace period in which you may maintain with payment of a late fee and submission of the required continuing education credits/continuing involvement. If you do not respond by the end of the grace period, you will be decertified and will receive notification of this action. Can I reinstate my Certification if it has expired? A certificant who has had a credential revoked due to not meeting the Certification maintenance requirements may re-apply for Certification. The individual must meet the current eligibility requirements, pay all required fees, and successfully pass the exam.
Page|36v.10/11
NON-DISCRIMINATION POLICY
It is ACRP/APPIs philosophy and policy to avoid discrimination based on race, color, national origin, sex, age, religion, marital status, sexual orientation, or other status or condition that is protected by applicable law.
CONFIDENTIALITY
The Academy protects the confidential information of applicants and certificants. In addition to personal information submitted in the application, exam results are also considered confidential. Unless otherwise required by law, confidential information will only be released to the individual applicant/certificant unless a signed release is provided.
VERIFICATION OF CREDENTIALS
An individuals Certification status may be verified through the searchable Academy registry on the ACRP website. Requests for written verification may be requested by contacting the Academy office and will require a signed release from the certificant.
Page|37v.10/11
APPENDIX 1 SAMPLE CV
Betty Smith, R.N., B.S.N. 233 ABC Drive Arlington, VA 22314 703-555-1111 Education: XYZ State University Bachelor of Science in Nursing August 2003 Clinical Research Education only required if claiming completion in lieu of 1 year of CRA experience Name of School CCC, Program Title: ABCs of Clinical Research, Name of Organization that Accredits the Educational Institution Providing this Program Accrediting Bureau of Health Education Schools, Dates Attended From To 10/07 10/08 Professional Experience: Clinical Research Associate JKL Hospital Research Department Job Duties: Assists with investigational study selection and project negotiation, including initial site/sponsor correspondence, budget preparation, regulatory document preparations for protocol, informed consent and appropriate HIPPA inclusions for IRB submission. Ongoing management of study review process according to site/sponsor/IRB guidelines. Responsible for patient screening, recruitment, consent process and enrollment for ongoing clinical research projects, including all follow up management visits and case report form completion. Maintains source documentation and drug/device accountability. Conducts staff in-services prior to implementation of new research trials. 12/1/2005 to present
Cardiovascular Nurse Clinician / Clinical Research Associate University of XYZ Medical Center Division of Cardiovascular Diseases Job Duties:
6/22/2004 to 11/30/2005
Responsible for managing protocols, patient consent forms, patient screening, source documents, recruitment and follow up management. Completed case report forms and regulatory documents. Participated with physician on hospital rounds and discharge teaching. Performed noninvasive exercise and echocardiographic exercise testing.
Page|38v.10/11
SpecialAccommodationsRequestForm
Pleasehavethisformcompletedbyanappropriate,licensedhealthprofessionaltoensurethat Prometricisabletoprovideareasonableexaminationaccommodation.Theinformationyouprovide andanydocumentationregardingyourdisabilityandyourneedforaccommodationintestingwillbe treatedwithstrictconfidentiality. PleasesubmitthisformwithyourCertificationapplicationorfaxto7032548102 Attn:CertificationProgram byJanuary23,2012
ProfessionalDocumentation:
Ihaveknown__________________________________________since________________inmy ExamCandidate Date capacityas____________________________________(Professionaltitle).Thecandidatediscussed withmethenatureoftheexaminationtobeadministered.Itismyopinionthatbecauseofthis candidatesdisabilitydescribedbelow,he/sheshouldbeaccommodatedbyprovidingthespecial arrangementsindicatedbelow. Disability:______________________________________________________________________ _______________________________________________________________________________ Pleasecheckallthatapply: Extendedtestingtime: hour 1hour 3hours Enlargedtext Other(describe): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
March2012ExamTransferRequestForm
MustbereceivedbytheAcademyby10March2012 TheAcademyoffersaonetimetransferofanapplicantsapplicationfromoneexamcycletothenext. Therearetwosituationsinwhichapplicantsmaytakeadvantageofthisoption: 1. IfanapplicantisdeterminedIneligibleforthecurrentexamwindow,butwillhavemetthe eligibilityrequirementsbythenextexamwindow 2. IfanapplicantisdeterminedEligible,butmustwithdrawfromtheexamwindow(upto5 daysbeforeascheduledexamappointmenttime)* Ifyouwishtotransferyourapplication,youmaytransfertothenextexamcycleonly.Allfeeswill becomenonrefundable.Ifforanyreasonyouareunabletotaketheexamduringournextexam cycle,allfeeswillbeforfeited. *YoumustcancelyourexamappointmentwithPrometrictestingcentersbeforesubmittingthisform. PleasenotethatifyoupaidtheMemberRatefortheexam,youwillneedtokeepyourMembership currentforthenextexamcycle.IfyourMembershipexpiresbeforethenextexamcycle,youwill needtorenewyourMembership,orpaythedifferencebetweenMemberandStandardExamFees. CandidateName(printed):________________________________________________ NameofExam:__________________________________________________________ ReasonforTransfer:______________________________________________________ IhavereadtheTransferTerms&Conditionspage IhavecanceledmyexamappointmentwithPrometric(ifonewasscheduled)at800853 6769. CandidateSignature:_______________________________________ [email protected],orfaxitto7032548102by10March2012. Date:_____________
Page|40v.10/11
EmergencyExamCancellationForm
Tobecompletedwithinseven(7)days Usually,ifacandidatedoesnotcancelhis/herscheduledexamappointmentatleastfive(5)days priortothescheduleddate,ordoesnotappearfortheexamasscheduled,he/sheforfeitsallfees. However,ifacandidatewillbeunabletokeeptheirexamappointmentduetoanemergency situationthatariseswithinlessthanfive(5)dayspriororthedayofthescheduledexam appointmentdate,theAcademymayconsiderwaivingtheforfeitedfee. Inordertobeconsideredforsuchawaiver,thecandidateisrequiredtosubmittheEmergency ExamCancellationFormalongwithaccepted,official,supportingdocumentationoftheemergency totheAcademyatcertification@acrpnet.org.ThisinformationshouldbereceivedbytheAcademy beforethecandidatesscheduledexamdateorassoonastheemergencyhaspassedbutnolater thanseven(7)daysafterthescheduledexamdate. Thefollowingsituationswillbeconsidered: Emergencyroomvisitorhospitalization Severemedicalconditionrequiringhospitalization Deathofanimmediatefamilymember(spouse,child/dependent,parent,grandparent,sibling) Juryduty Calltoactivemilitaryduty Notificationanddocumentationoftheemergencymustbesubmittedbythecandidatetothe Academynolaterthanseven(7)calendardayspastthescheduledexamdate. EmailthisformandcorrespondingdocumentationtotheAcademyatcertification@acrpnet.org NOLATERTHANSEVEN(7)DAYSAFTERASCHEDULEDEXAMDATE.Faxisalsoaccepted703.254.8102. CandidateName: DateofMissedExam: Reason: SupportingDocumentTypeAttached(e.g.Emergencyroomrelease,deathcertificate):
Page|41v.10/11
DuplicateCertificateRequestForm
ThosecurrentlyholdingaCertificationthroughtheAcademymayrequestaduplicatecopyoftheir certificate.A$25.00USDfeewillbechargediftherequestismademorethanthree(3)months aftertheoriginalcertificatewasissued.Ifyouwouldalsolikeacopyofyourcertificatefaxedore mailedtoyou,pleaseindicatethatbelow. Theserequestscanonlybemadebythecurrentcertificant. Pleaseselectallthatapply: Iamrequestingaduplicatecertificate,andincludemyaddressandpayment informationbelow. Iamrequestingthataduplicatecertificatealsobefaxed* Iamrequestingthataduplicatecertificatealsobeemailed* CertificantName(printed): CertificantSignature: Date: *FaxNumberorEmailAddress: MailingAddress: State: Zipcode: City: PaymentInformation METHODOFPAYMENT: CheckMCVisaAMEX (circleone) ExpirationDate: CreditCardNumber: TotalAmountDue$ [email protected],orfaxitto7032548102.
Page|42v.10/11