The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

pIAUnEomVDHhwGz7oYJ3Q3Xw9SFoPeg

UM eReg External Reviewer Account Request Form

**This request form is for individuals who do not work at the University of Michigan and who require access to the University of Michigan's eRegulatory Application for Remote Monitoring or Auditing of a clinical research trial or clinical research study.**

Dear Study Team Member -

Please complete the form below to either:

Request an eReg Reviewer account for your external study monitors or auditors. All information is required to complete the request.
Request to deactivate an existing eReg Reviewer Account.

To avoid duplicates account requests, please check eReg for existing accounts before submitting a request. To search, log in to eReg, and navigate to Menu > Admin > Contacts > Search by Username or Name. If an account already exists for this user, do not submit another request.

PLEASE NOTE: For new Reviewer accounts, External personnel will be issued UM Level 1 and Level 2 credentials. This process can take approximately 2 weeks to complete depending on how quickly the external person responds with the required information for the credentials. The CTSU's will be contacting the external person with specific instructions to gather the required information and then request the account. External personnel will be also be required to complete a short training on eReg prior to being issued an eReg account.

Individuals requesting an account for monitoring or auditing will only be given a Reviewer role which has limited access in eReg. Review Sessions are set up by the study team with a specific time period and access to only those records specified by the study team. No additional permission or access will be granted to external personnel.

For questions, please submit a ticket to the eReg Support Team and reference the external person's full name and note that you have questions about a reviewer account for external personnel.

Thank you,
eReg Support Team

Account Request Date:

External Reviewer Account
Would you like to:

* must provide value

Request New External Reviewer Account

Deactivate Existing External Reviewer Account

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First and Last Name of person completing this form:

NOTE: To be completed by University of Michigan Study Team Members or Support Personnel Only

* must provide value

Email Address of person completing the form
Email address must end in med.umich.edu or umich.edu

* must provide value

For the Person completing this form:
What is the primary CTSU you are affiliated with?

* must provide value

Michigan CTSU (M-CTSU)

Oncology CTSU (O-CTSU)

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Please list all HUM #'s, Intake #'s, or UMCC#'s associated with this request

* must provide value

Please complete the following information about the External Monitor or Auditor for which you are requesting an eReg Reviewer Account or deactivation of an eReg Reviewer Account.

External User First Name

* must provide value

External User Last Name

* must provide value

External User Email Address

Please double check the email address to verify correctness.
Please ensure there are no leading or trailing spaces in the email address entered.
Email address must match third party vendor who employs the external user.

* must provide value

Company Name where External Person is Employed

* must provide value

Does the external person have Michigan Medicine Level 1 credentials?

Yes

Unsure

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Does the external person have Michigan Medicine Level 2 credentials?

Yes

Unsure

reset

Uniqname for External User

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.