Ich E6 (R3)

25 May 2023
EMA/CHMP/ICH/135/1995
Committee for Human Medicinal Products
ICH E6 (R3) Guideline on good clinical practice (GCP)

Step 2b
Transmission to CHMP 25 May 2023
Adoption by CHMP 25 May 2023
Release for public consultation 26 May 2023
Deadline for comments 26 September 2023
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INTERNATIONAL COUNCIL FOR HARMONISATION OF TECHNICAL
REQUIREMENTS FOR PHARMACEUTICALS FOR HUMAN USE
ICH HARMONISED GUIDELINE
GOOD CLINICAL PRACTICE (GCP)

E6(R3)
Draft version
Endorsed on 19 May 2023
Currently under public consultation
At Step 2 of the ICH Process, a consensus draft text or guideline, agreed by the appropriate
ICH Expert Working Group, is transmitted by the ICH Assembly to the regulatory authorities
of the ICH regions for internal and external consultation, according to national or regional
procedures.
E6(R3)
Document History
Code History Date
E6 Approval by the Steering Committee under Step 2 27 April 1995
and release for public consultation.
E6 Approval by the Steering Committee under Step 4 1 May 1996
and recommended for adoption to the three ICH
regulatory bodies.
E6(R1) Approval by the Steering Committee of Post-Step 4 10 June 1996
editorial corrections.
E6(R2) Adoption by the Regulatory Members of the ICH 9 November 2016
Assembly under Step 4. Integrated Addendum to
ICH E6(R1) document. Changes are integrated
directly into the following sections of the parental
Guideline: Introduction, 1.63, 1.64, 1.65, 2.10, 2.13,
4.2.5, 4.2.6, 4.9.0, 5.0, 5.0.1, 5.0.2, 5.0.3, 5.0.4,
5.0.5, 5.0.6, 5.0.7, 5.2.2, 5.5.3 (a), 5.5.3 (b), 5.5.3 (h),
5.18.3, 5.18.6 (e), 5.18.7, 5.20.1, 8.1
E6(R3) Endorsement by the Members of the ICH Assembly 19 May 2023
under Step 2 and release for public consultation.
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ii
ICH E6(R3) Guideline
ICH HARMONISED GUIDELINE
GOOD CLINICAL PRACTICE (GCP)

E6(R3)
ICH Consensus Guideline
TABLE OF CONTENTS
I. INTRODUCTION........................................................................................................ 1
Guideline Scope ........................................................................................................................ 1
Guideline Structure ................................................................................................................. 1
II. PRINCIPLES OF ICH GCP ....................................................................................... 2
III. ANNEX 1 ...................................................................................................................... 7
1. INSTITUTIONAL REVIEW BOARD/INDEPENDENT ETHICS COMMITTEE
(IRB/IEC)...................................................................................................................... 7
1.1 Responsibilities ............................................................................................................. 7
1.2 Composition, Functions and Operations ................................................................... 9
1.3 Procedures .................................................................................................................... 9
1.4 Records........................................................................................................................ 10
1.5 Submission and Communication .............................................................................. 11
2. INVESTIGATOR ...................................................................................................... 11
2.1 Qualifications and Training ...................................................................................... 11
2.2 Resources .................................................................................................................... 11
2.3 Responsibilities ........................................................................................................... 11
2.4 Communication with IRB/IEC ................................................................................. 12
2.5 Compliance with Protocol ......................................................................................... 12
2.6 Premature Termination or Suspension of a Trial................................................... 13
2.7 Participant Medical Care and Safety Reporting..................................................... 13
2.7.1 Medical Care of Trial Participants ........................................................... 13
2.7.2 Safety Reporting ........................................................................................ 14
2.8 Informed Consent of Trial Participants .................................................................. 14
2.9 End of Participation in a Clinical Trial ................................................................... 18
2.10 Investigational Product Management ...................................................................... 19
2.11 Randomisation Procedures and Unblinding ........................................................... 19
i
2.12 Records........................................................................................................................ 20
2.13 Clinical Trial/Study Reports ..................................................................................... 21
3. SPONSOR................................................................................................................... 22
3.1 Trial Design ................................................................................................................ 22
3.2 Resources .................................................................................................................... 22
3.3 Allocation of Activities ............................................................................................... 22
3.4 Qualification and Training........................................................................................ 22
3.4.1 Medical Expertise ...................................................................................... 22
3.5 Financing .................................................................................................................... 23
3.6 Agreements ................................................................................................................. 23
3.7 Investigator Selection................................................................................................. 24
3.8 Communication with IRB/IEC and Regulatory Authority(ies) ............................ 24
3.8.1 Notification/Submission to Regulatory Authority(ies) .............................. 24
3.8.2 Confirmation of Review by IRB/IEC ......................................................... 25
3.9 Sponsor Oversight...................................................................................................... 25
3.10 Quality Management ................................................................................................. 26
3.10.1 Risk Management ...................................................................................... 26
3.11 Quality Assurance and Quality Control .................................................................. 27
3.11.1 Quality Assurance ..................................................................................... 27
3.11.2 Audit .......................................................................................................... 27
3.11.3 Quality Control.......................................................................................... 28
3.11.4 Monitoring ................................................................................................. 28
3.12 Noncompliance ........................................................................................................... 33
3.13 Safety Assessment and Reporting............................................................................. 33
3.13.1 Sponsor Review of Safety Information ...................................................... 34
3.13.2 Safety Reporting ....................................................................................... 34
3.13.3 Managingan Immediate Hazard ................................................................ 35
3.14 Insurance/Indemnification/Compensation to Participants and Investigators ..... 35
3.15 Investigational Product(s) ......................................................................................... 35
3.15.1 Information on Investigational Product(s) ................................................ 35
3.15.2 Manufacturing, Packaging, Labelling and Coding Investigational
Product(s) ............................................................................................................. 35
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3.15.3 Supplying and Handling Investigational Product(s) ................................. 36

3.16 Data and Records ....................................................................................................... 37
3.16.1 Data Handling ........................................................................................... 37
3.16.2 Statistical Programming and Data Analysis ............................................. 41
3.16.3 Record Keeping and Retention .................................................................. 41
3.16.4 Record Access............................................................................................ 42
3.17 Reports ........................................................................................................................ 42
3.17.1 Premature Termination or Suspension of a Trial ..................................... 42
3.17.2 Clinical Trial/Study Reports ...................................................................... 42
4. DATA GOVERNANCE – INVESTIGATOR AND SPONSOR............................ 43
4.1 Safeguard Blinding in Data Governance ................................................................. 43
4.2 Data Life Cycle Elements .......................................................................................... 44
4.2.1 Data Capture ............................................................................................. 44
4.2.2 Relevant Metadata, Including Audit Trails ............................................... 44
4.2.3 Review of Data and Metadata ................................................................... 45
4.2.4 Data Corrections ....................................................................................... 45
4.2.5 Data Transfer, Exchange and Migration .................................................. 45
4.2.6 Finalisation of Data Sets Prior to Analysis............................................... 45
4.3 Computerised Systems............................................................................................... 45
4.3.1 Procedures for the Use of Computerised Systems..................................... 46
4.3.2 Training ..................................................................................................... 46
4.4 Security of Computerised Systems ........................................................................... 46
4.5 Validation of Computerised Systems ....................................................................... 46
4.6 System Failure ............................................................................................................ 47
4.7 Technical Support ...................................................................................................... 47
4.8 User Management ...................................................................................................... 48
GLOSSARY............................................................................................................................ 49
APPENDICES ........................................................................................................................ 58
Appendix A. INVESTIGATOR’S BROCHURE ................................................................ 58
A.1 Introduction ................................................................................................................ 58
A.2 General Considerations ............................................................................................. 59
A.2.1 Title Page .................................................................................................. 59
iii
A.2.2 Confidentiality Statement .......................................................................... 59

A.3 Contents of the Investigator’s Brochure .................................................................. 59
A.3.1 Table of Contents....................................................................................... 59
A.3.2 Summary .................................................................................................... 59
A.3.3 Introduction ............................................................................................... 59
A.3.4 Physical, Chemical and Pharmaceutical Properties and Formulation .... 59
A.3.5 Nonclinical Studies .................................................................................... 60
A.3.6 Effects in Humans ...................................................................................... 61
A.3.7 Summary of Data and Guidance for the Investigator ............................... 62
Appendix B. CLINICAL TRIAL PROTOCOL AND PROTOCOL AMENDMENT(S)
...................................................................................................................................... 64
B.1 General Information .................................................................................................. 64
B.2 Background Information .......................................................................................... 64
B.3 Trial Objectives and Purpose ................................................................................... 64
B.4 Trial Design ................................................................................................................ 65
B.5 Selection of Participants ............................................................................................ 65
B.6 Withdrawal of Consent or Discontinuation of Participation ................................. 65
B.7 Treatment and Interventions for Participants ........................................................ 66
B.8 Assessment of Efficacy ............................................................................................... 66
B.9 Assessment of Safety .................................................................................................. 66
B.10 Statistical Considerations .......................................................................................... 66
B.11 Direct Access to Source Records .............................................................................. 67
B.12 Quality Control and Quality Assurance .................................................................. 67
B.13 Ethics ........................................................................................................................... 67
B.14 Data Handling and Record Keeping ........................................................................ 67
B.15 Financing and Insurance ........................................................................................... 67
B.16 Publication Policy....................................................................................................... 67
Appendix C. ESSENTIAL RECORDS FOR THE CONDUCT OF A CLINICAL TRIAL
...................................................................................................................................... 68
C.1 Introduction ................................................................................................................ 68
C.2 Management of Essential Records ........................................................................... 68
C.3 Essentiality of Trial Records ..................................................................................... 69
1
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1 I. INTRODUCTION
2 Good Clinical Practice (GCP) is an international, ethical, scientific and quality standard for the
3 conduct of trials that involve human participants. Clinical trials conducted in accordance with
4 this standard will help to assure that the rights, safety and well-being of trial participants are
5 protected; that the conduct is consistent with the principles that have their origin in the
6 Declaration of Helsinki; and that the clinical trial results are reliable. The term “trial conduct”
7 in this document includes processes from planning to reporting, including planning, initiating,
8 performing, recording, oversight, evaluation, analysis and reporting activities as appropriate.
9 The objective of this ICH GCP Guideline is to provide a unified standard to facilitate the mutual
10 acceptance of clinical trial data for ICH member countries and regions by applicable regulatory
11 authorities.
12 This guideline builds on key concepts outlined in ICH E8(R1) General Considerations for
13 Clinical Studies. This includes fostering a quality culture and proactively designing quality into
14 clinical trials and drug development planning, identifying factors critical to trial quality, and
15 engaging stakeholders, as appropriate, using a proportionate risk-based approach.
16 Clinical trials vary widely in scale, complexity and cost. Careful evaluation of the priorities
17 involved in each trial and the risks associated with the priorities will help ensure efficiency by
18 focusing on activities critical to achieving the trial objectives.
19 Guideline Scope
20 This guideline applies to interventional clinical trials of investigational products 1 that are
21 intended to be submitted to regulatory authorities. This guideline may also be applicable to
22 other interventional clinical trials of investigational products that are not intended to support
23 marketing authorisation applications in accordance with local requirements.
24 Guideline Structure
25 This ICH GCP Guideline is composed of principles and annexes that expand on the principles,
26 with specific details for different types of clinical trials. The principles are intended to apply
27 across clinical trial types and settings and to remain relevant as technological and
28 methodological advances occur. The principles outlined in this guideline may be satisfied using
29 differing approaches and should be applied to fit the intended purpose of the clinical trial.
30 Annex-1 is intended to provide information on how the principles can be appropriately applied
31 to clinical trials. Additional annexes may be developed to respond to stakeholder needs and to
32 address emerging innovations in trial design and conduct. This guideline should be read in
33 conjunction with other ICH guidelines relevant to the design and conduct of clinical trials,
34 including multiregional trials.
1
For the purpose of this guideline, the term “investigational products” should be considered synonymous with
drugs, medicines, medicinal products, vaccines and biological products.
1
35 II. PRINCIPLES OF ICH GCP

36 Clinical trials are a fundamental part of clinical research that support the development of new
37 medicines or uses of existing medicines. Well-designed and conducted clinical trials help
38 answer key questions in healthcare and drug development. Their results are essential for
39 evidence-based healthcare decisions. Trials with inadequate design and/or poorly conducted
40 trials may place participant safety at risk and yield inadequate or unreliable evidence and are
41 unethical. They waste resources and the efforts and time of investigators and participants.
42 The principles of GCP are designed to be flexible and applicable to a broad range of clinical
43 trials. This guideline, along with ICH E8(R1), encourages thoughtful consideration and
44 planning to address specific and potentially unique aspects of an individual clinical trial. This
45 includes evaluation of trial characteristics, such as the design elements, the investigational
46 product being evaluated, the medical condition being addressed, the characteristics of the
47 participants, the setting in which the clinical trial is being conducted, and the type of data being
48 collected. Careful consideration of factors relevant to ensuring trial quality is needed for each
49 clinical trial.
50 The principles are intended to support efficient approaches to trial design and conduct. For
51 example, innovative digital health technologies, such as wearables and sensors, may expand
52 the possible approaches to trial conduct. Such technologies can be incorporated into existing
53 healthcare infrastructures and enable the use of a variety of relevant data sources in clinical
54 trials. This will aid in keeping clinical trial conduct in line with advancing science and
55 technological developments. The use of technology in the conduct of clinical trials should be
56 adapted to fit the participant characteristics and the particular trial design. This guideline is
57 intended to be media neutral to enable the use of different technologies for the purposes of
58 documentation.
59 The use of innovative clinical trial designs and technologies may help include diverse patient
60 populations, as appropriate, and enable wider participation. The design of the trial, to ensure
61 appropriate quality and meaningful trial outcomes, may be supported by the perspectives of
62 stakeholders; for example, patients and/or healthcare providers. Their input can increase the
63 likelihood of meaningful trial outcomes, which are relevant to both trial participants and future
64 patients. This input will also guide decisions on the feasibility of data collection and assure that
65 participation in the trial does not become unduly burdensome for those involved.
66 Clinical trials should be designed to protect the rights, safety and well-being of participants and
67 assure the reliability of results. Quality by design should be implemented to identify the factors
68 (i.e., data and processes) that are critical to ensuring trial quality and the risks that threaten the
69 integrity of those factors and ultimately the reliability of the trial results. Clinical trial processes
70 and risk mitigation strategies implemented to support the conduct of the trial should be
71 proportionate to the importance of the data being collected and the risks to trial participant
72 safety and data reliability. Trial designs should be operationally feasible and avoid unnecessary
73 complexities.
74 The overarching principles provide a flexible framework for clinical trial conduct. They are
75 structured to provide guidance throughout the life cycle of the clinical trial. These principles
76 are applicable to trials involving human participants. The principles are interdependent and
77 should be considered in their totality to assure ethical trial conduct and reliable results.
2
78 1. Clinical trials should be conducted in accordance with the ethical principles that
79 have their origin in the Declaration of Helsinki and that are consistent with GCP
80 and applicable regulatory requirement(s). Clinical trials should be designed and
81 conducted in ways that ensure the rights, safety and well-being of participants.
82
83 1.1 The rights, safety and well-being of the participants are the most important
84 considerations and should prevail over interests of science and society.
85 1.2 The safety of the participants should be reviewed periodically as new safety
86 information becomes available, which could have an impact on the participant
87 or the conduct of the trial.
88 1.3 Foreseeable risks and inconveniences should be weighed against the anticipated
89 benefits for the individual participants and society. A trial should be initiated
90 and continued only if the anticipated benefits justify the known and anticipated
91 risks.
92 1.4 When designing a clinical trial, the scientific goal and purpose should be
93 carefully considered so as not to unnecessarily exclude particular participant
94 populations. The participant selection process should be representative of the
95 anticipated population who is likely to use the medicinal product in future
96 clinical practice to allow for generalising the results across the broader
97 population. Certain trials (e.g., early phase, proof of concept trials,
98 bioequivalence studies) may not require a heterogeneous population.
99 1.5 A qualified physician or, when appropriate, a qualified dentist (or other
100 qualified healthcare professionals in accordance with local regulatory
101 requirements) should have the overall responsibility for the trial-related medical
102 care given to, and medical decisions made on behalf of, participants; however,
103 the practical interactions and the delivery of medical care and decisions can be
104 carried out by appropriately qualified healthcare professionals in accordance
105 with applicable regulatory requirements.
106 1.6 The confidentiality of information that could identify participants should be
107 protected in accordance with applicable privacy and data protection
108 requirements.
109
110 2. Informed consent is an integral feature of the ethical conduct of a trial. Clinical
111 trial participation should be voluntary and based on a consent process that
112 ensures participants (or their legally acceptable representatives, where
113 applicable) are well-informed.
114
115 2.1 Freely given informed consent should be obtained and documented from every
116 participant prior to clinical trial participation. For potential participants unable
117 to provide informed consent, their legally acceptable representative should
118 provide consent prior to clinical trial participation.
119 2.2 The process and information provided should be designed to achieve the
120 primary objective of enabling potential trial participants to evaluate the benefits
121 and risks of participating in the trial and to make an informed decision on
122 whether or not to participate in the trial. The information provided during the
3
123 informed consent process should be clear and concise so as to be understandable

124 by potential participants or legally acceptable representatives.
125 2.3 The informed consent process should take into consideration relevant aspects
126 of the trial, such as the characteristics of the participants, the trial design, the
127 anticipated benefit and risk of medical intervention(s), the setting and context
128 in which the trial will be conducted (e.g., trials in emergency situations), and
129 the potential use of technology to inform participants (or their legally
130 acceptable representatives) and obtain informed consent.
131
132 3. Clinical trials should be subject to an independent review by an institutional
133 review board/independent ethics committee (IRB/IEC).
134
135 3.1 A trial should always be conducted in compliance with the protocol that
136 receives prior IRB/IEC approval/favourable opinion.
137 3.2 Periodic review of the trial by the IRB/IEC should also be conducted in
138 accordance with applicable regulatory requirements.
139
140 4. Clinical trials should be scientifically sound for their intended purpose and based
141 on robust and current scientific knowledge and approaches.
142
143 4.1 The available nonclinical and clinical information on an investigational
144 product(s) should be adequate to support the proposed clinical trial.
145 4.2 Clinical trials should be scientifically sound and reflect the state of knowledge
146 and experience with the investigational product(s), including, if applicable, the
147 condition to be treated, diagnosed or prevented; the current understanding of
148 the underlying biological mechanism (of both the condition and the treatment);
149 and the population for which the investigational product is intended.
150 4.3 There should be periodic review of current scientific knowledge and approaches
151 to determine whether modifications to the trial are needed, since new or
152 unanticipated information may arise once the trial has begun.
153
154 5. Clinical trials should be designed and conducted by qualified individuals.
155
156 5.1 Individuals with different expertise and training may be needed across all
157 phases of a clinical trial, such as physicians, scientists, ethicists, technology
158 experts, trial coordinators, monitors, auditors and statisticians. Individuals
159 involved in a trial should be qualified by education, training and experience to
160 perform their respective task(s).
161
162 6. Quality should be built into the scientific and operational design and conduct of
163 clinical trials.
164
165 6.1 Quality of a clinical trial is considered in this guideline as fit for purpose. The
166 quality and amount of the information generated during a clinical trial should
167 support good decision making.
4
168 6.2 Factors critical to the quality of the trial should be identified. These factors are
169 attributes of a trial that are fundamental to the protection of participants, the
170 reliability and interpretability of the trial results and the decisions made based
171 on those trial results. Quality by design involves focusing on the design of all
172 components of the trial in order to maximise the likelihood of trial success (i.e.,
173 that the trial will answer the research question).
174 6.3 Strategies should be implemented to avoid, detect and address serious non-
175 compliance with GCP, the trial protocol and applicable regulatory requirements
176 to prevent recurrence.
177
178 7. Clinical trial processes, measures and approaches should be implemented in a
179 way that is proportionate to the risks to participants and to the importance of
180 the data collected.
181
182 7.1 Trial processes should be proportionate to the risks inherent in the trial and the
183 importance of the information collected. Risks in this context include risks to
184 the rights, safety and well-being of trial participants as well as risks to the
185 reliability of the trial results.
186 7.2 The focus should be on the risks to participants beyond those associated with
187 standard medical care. The risks relating to investigational products that have a
188 marketing authorisation when used in the clinical trial context may differ from
189 the routine care of patients and should be taken into consideration.
190 7.3 Risks to critical to quality factors should be managed prospectively and
191 adjusted when new or unanticipated issues arise once the trial has begun.
192
193 8. Clinical trials should be described in a clear, concise and operationally feasible
194 protocol.
195
196 8.1 A well-designed trial protocol is fundamental to the protection of participants
197 and for the generation of reliable results.
198 8.2 The scientific objectives of any trial should be clear and explicitly stated in the
199 protocol.
200 8.3 The clinical trial protocol as well as the plans or documents for the protocol
201 execution (e.g., statistical analysis plan, data management plan, monitoring
202 plan) should be clear, concise and operationally feasible.
203
204 9. Clinical trials should generate reliable results.
205
206 9.1 The quality and amount of the information generated in a clinical trial should
207 be sufficient to provide confidence in the trial’s results and support good
208 decision making.
209 9.2 Systems and processes that aid in data capture, management and analyses, as
210 well as those that help ensure the quality of the information generated from the
211 trial, should be fit for purpose, should capture the data required by the protocol
212 and should be implemented in a way that is proportionate to the risks to
213 participants and the importance of acquired data.
5
214 9.3 Trial processes should be operationally feasible and avoid unnecessary
215 complexity, procedures and data collection. Trial processes should support the
216 key trial objectives.
217 9.4 Computerised systems used in clinical trials should be fit for purpose, and
218 factors critical to their quality should be addressed in their design or adaptation
219 for clinical trial purposes.
220 9.5 Clinical trials should incorporate efficient and well-controlled processes for
221 managing records through appropriate management of data integrity,
222 traceability and protection of personal information, thereby allowing the
223 accurate reporting, interpretation and verification of the clinical trial-related
224 information.
225 9.6 Clinical trial-related records should be retained securely by sponsors and
226 investigators for the required period of time and should be available to
227 regulatory authorities upon request to enable reconstruction of the trial conduct
228 and results in order to ensure the reliability of trial results.
229 9.7 The transparency of clinical trials in drug development includes registration on
230 publicly accessible and recognised databases and the public posting of clinical
231 trial results.
232
233 10. Roles and responsibilities in clinical trials should be clear and documented
234 appropriately.
235
236 10.1 The sponsor may transfer or the investigator may delegate some or all their
237 tasks, duties or functions (hereafter referred to as activities), but they retain
238 overall responsibility for their respective activities.
239 10.2 Agreements should clearly define the roles, activities and responsibilities for
240 the clinical trial and be documented appropriately. Where activities have been
241 transferred or delegated to service providers, the responsibility for the conduct
242 of the trial, including quality and integrity of the trial data, resides with the
243 sponsor or investigator, respectively.
244 10.3 The sponsor or investigator should maintain appropriate oversight or
245 supervision of the aforementioned activities, respectively.
246
247 11. Investigational products used in a clinical trial should be manufactured in
248 accordance with applicable Good Manufacturing Practice (GMP) standards and
249 be stored, shipped, handled and disposed of in accordance with the product
250 specifications and the trial protocol.
251
252 11.1 Investigational products used in a clinical trial should be manufactured in
253 accordance with applicable GMP standards.
254 11.2 Measures should be in place to ensure that the investigational product provided
255 to trial participants retains its quality.
256 11.3 Investigational products should be used in accordance with the protocol and
257 relevant trial documents.
6
258 11.4 Manufacturing, handling and labelling of investigational products should be

259 undertaken in a manner that aligns with treatment assignment and maintains
260 blinding, where applicable.
261 11.5 Investigational product labelling should follow applicable regulatory
262 requirements.
263 11.6 Adequate measures to ensure that the investigational product is handled and
264 shipped appropriately should be implemented.
265
266 III. ANNEX 1
267 1. INSTITUTIONAL REVIEW BOARD/INDEPENDENT ETHICS COMMITTEE
268 (IRB/IEC)
269 The IRB/IEC is responsible for the ethical review of the trial. The requirements for
270 the IRB/IEC in this guideline should be read in conjunction with local regulatory
271 requirements.
272 1.1 Responsibilities
273 1.1.1 The purpose of an IRB/IEC is to safeguard the rights, safety and well-being of all trial
274 participants.
275
276 1.1.2 The IRB/IEC should review the following information, where applicable:
277
278 (a) protocol and any amendments;
279
280 (b) informed consent material(s), assent form(s), where applicable, and any
281 updates, including the description of the process for how informed consent is
282 to be obtained;
283
284 (c) Investigator’s Brochure or current scientific information, such as a basic
285 product information brochure (e.g., Summary of Product Characteristics
286 (SmPC), package leaflet or labelling), as appropriate, including their updates;
287
288 (d) any other information to be provided to the trial participant(s), including a
289 description of the media through which such information will be provided;
290
291 (e) advertisement for participant recruitment (if used) and information on the
292 recruitment process;
293
294 (f) plans to compensate participants (if any);
295
296 (g) ongoing updates to safety information (dependent on requirements of the
297 IRB/IEC);
298
299 (h) investigator’s current curriculum vitae and/or other documentation evidencing
300 qualifications;
301
7
302 (i) any other documents that the IRB/IEC may need to fulfil its responsibilities.
303
304 1.1.3 The IRB/IEC should review a proposed clinical trial within a reasonable time and
305 document its reviews clearly identifying the trial, the documents reviewed and the
306 dates for the following:
307
308 (a) approval/favourable opinion;
309
310 (b) modifications required prior to its approval/favourable opinion;
311
312 (c) disapproval/negative opinion;
313
314 (d) termination/suspension of any prior approval/favourable opinion.
315
316 1.1.4 The IRB/IEC should conduct continuing review of each ongoing trial at intervals
317 appropriate to the degree of risk to participants.
318
319 1.1.5 The IRB/IEC may request more information than is outlined in section 2.8.11 be given
320 to participants when, in the judgement of the IRB/IEC, the additional information
321 would add meaningfully to the protection of the rights, safety and/or well-being of the
322 participants.
323
324 1.1.6 Where the protocol indicates that prior consent of the trial participant or the
325 participant’s legally acceptable representative is not possible (see section 2.8.9), the
326 IRB/IEC should determine that the proposed protocol and/or other document(s)
327 adequately address relevant ethical concerns and meet applicable regulatory
328 requirements for such trials (e.g., in emergency situations).
329
330 1.1.7 If minors are to be included in a trial, the IRB/IEC should review the assent
331 information considering the age, maturity and psychological state of the minor, as
332 well as applicable regulatory requirements.
333
334 1.1.8 If the trial participants are compensated for their participation in the trial, the IRB/IEC
335 should review both the amount and method of payment to participants to assure that
336 neither presents problems of coercion or undue influence on the trial participants.
337 Payments to a participant should be prorated and not wholly contingent on completion
338 of the trial by the participant. Reasonable reimbursement of participants for travel and
339 lodging is not typically coercive.
340
341 1.1.9 The IRB/IEC should ensure that information regarding payment to participants,
342 including the methods, amounts and schedule of payment to trial participants, is set
343 forth in the informed consent material and any other information to be provided to
344 participants.
8
345 1.2 Composition, Functions and Operations

346 1.2.1 The IRB/IEC should consist of a reasonable number of members who collectively
347 have the qualifications and experience to review and evaluate the science, medical
348 aspects and ethics of the proposed trial. It is recommended that the IRB/IEC should
349 include:
350
351 (a) at least five members;
352
353 (b) at least one member whose primary area of interest is not in medical sciences;
354
355 (c) at least one member who is independent of the institution/investigator site.
356
357 Only those IRB/IEC members who are independent of the investigator and the sponsor
358 of the trial should vote/provide an opinion. A list of IRB/IEC members and their
359 qualifications should be maintained.
360
361 1.2.2 The IRB/IEC should perform its functions according to documented operating
362 procedures, should maintain records of its activities and minutes of its meetings, and
363 should comply with GCP and with the applicable regulatory requirement(s).
364
365 1.2.3 An IRB/IEC should make its decisions at announced meetings at which at least a
366 quorum, as stipulated in its documented operating procedures, is present.
367
368 1.2.4 Only members who participate in the IRB/IEC review and discussion should
369 vote/provide their opinion and/or advise.
370
371 1.2.5 The investigator, investigator site staff and/or sponsor, where appropriate, may
372 provide information on any aspect of the trial but should not participate in the decision
373 making of the IRB/IEC or in the vote/opinion of the IRB/IEC.
374
375 1.2.6 An IRB/IEC may invite non-members with expertise in special areas for assistance.
376 1.3 Procedures
377 The IRB/IEC should establish, document in writing or electronically, and follow its procedures,
378 which should include:
379 1.3.1 Determining its composition (names and qualifications of the members) and the
380 authority under which it is established;
381
382 1.3.2 Scheduling, notifying its members of and conducting its meetings;
383
384 1.3.3 Conducting initial and continuing review of trials;
385
386 1.3.4 Determining the frequency of continuing review, as appropriate;
387
9
388 1.3.5 Providing, according to the applicable regulatory requirements, expedited review and
389 approval/favourable opinion of minor change(s) in ongoing trials that have the
390 approval/favourable opinion of the IRB/IEC;
391
392 1.3.6 Specifying that no participant should be admitted to a trial before the IRB/IEC issues
393 its documented approval/favourable opinion of the trial;
394
395 1.3.7 Specifying that no deviations from the protocol should be initiated without prior
396 documented IRB/IEC approval/favourable opinion, except when necessary to
397 eliminate immediate hazards to the participants;
398
399 1.3.8 Specifying that the investigator/institution should promptly report to the IRB/IEC (see
400 section 1.5):
401
402 (a) deviations from the protocol to eliminate immediate hazards to the trial
403 participants (see sections 1.3.7, 2.5.3 and 2.5.4);
404
405 (b) changes increasing the risk to participants and/or significantly affecting the
406 conduct of the trial (see section 2.4.6);
407
408 (c) all suspected unexpected serious adverse reactions (SUSARs) in line with
409 applicable regulatory requirements;
410
411 (d) new information that may affect adversely the safety of the participants or the
412 conduct of the trial.
413
414 1.3.9 Ensuring that the IRB/IEC (see section 1.5) promptly notifies in writing or
415 electronically the investigator/institution or sponsor concerning:
416
417 (a) its trial-related decisions/opinions;
418
419 (b) the reasons for its decisions/opinions;
420
421 (c) procedures for appeal of its decisions/opinions.
422 1.4 Records
423 1.4.1 The IRB/IEC should retain all relevant records (e.g., documented procedures,
424 membership lists, lists of occupations/affiliations of members, submitted documents,
425 minutes of meetings and correspondence) in accordance with applicable regulatory
426 requirements and make them available upon request from the regulatory
427 authority(ies).
428
429 1.4.2 The IRB/IEC may be asked by investigators, sponsors or regulatory authorities to
430 provide its documented procedures and membership lists.
10
431 1.5 Submission and Communication

432 For the submission to or communication with the IRB/IEC, it is recognised that in most regions,
433 there is also a requirement to make a submission to the relevant regulatory authority, and these
434 may be combined, in line with applicable regulatory requirements, in a single submission in
435 some regions. In addition, applicable regulatory requirements may require that submissions to
436 the IRB/IEC are made in some regions by the investigator/institution and in others by the
437 sponsor.
438
439 2. INVESTIGATOR
440 2.1 Qualifications and Training
441 2.1.1 The investigator(s) should be qualified by education, training and experience to
442 assume responsibility for the proper conduct of the trial and should provide evidence
443 of such qualifications.
444
445 2.1.2 The investigator should be familiar with the appropriate use of the investigational
446 product(s) as described in the protocol, in the current Investigator’s Brochure, in the
447 product information and/or in other information sources provided by the sponsor.
448 2.2 Resources
449 2.2.1 The investigator should be able to demonstrate (e.g., based on retrospective or
450 currently available data) a potential for recruiting the proposed number of eligible
451 participants within the recruitment period as agreed with the sponsor.
452
453 2.2.2 The investigator should have sufficient time, an adequate number of available and
454 qualified staff, and adequate facilities for the foreseen duration of the trial to conduct
455 the trial properly and safely.
456 2.3 Responsibilities
457 2.3.1 The investigator may delegate trial-specific activities to other persons or parties.
458 The investigator may be supported by the sponsor to identify a suitable service
459 provider(s); however, the investigator retains the final decision on whether the service
460 provider intended to support the investigator is appropriate based on information
461 provided by the sponsor (see section 3.6.6).
462 The investigator retains the ultimate responsibility and maintains appropriate
463 supervision of the persons or parties undertaking the activities delegated to ensure the
464 rights, safety and well-being of the trial participants and data reliability.
465
466 2.3.2 The investigator should ensure that persons or parties to whom the investigator has
467 delegated trial-specific activities are appropriately qualified and supervised and are
468 adequately informed about the protocol, the investigational product(s) and their
469 assigned trial activities (including activities conducted by staff provided by other
470 parties, for example, home nurses arranged by the sponsor). Trial-related training to
11
471 persons assisting in the trial should correspond to what is necessary to enable them to
472 fulfil their delegated trial activities that go beyond their usual training and experience.
473
474 2.3.3 The investigator should ensure a record is maintained of the persons and parties to
475 whom the investigator has delegated significant trial-related activities. In situations
476 where the clinical trial activities are performed in accordance with routine clinical
477 care, delegation documentation may not be required.
478
479 2.3.4 Agreements made by the investigator/institution with service providers for trial-
480 related activities should be documented.
481
482 2.3.5 The investigator/institution should permit monitoring and auditing by the sponsor and
483 inspection by the appropriate regulatory authority(ies).
484 2.4 Communication with IRB/IEC
485 2.4.1 Submission to the IRB/IEC may be made by the investigator/institution or sponsor in
486 accordance with applicable regulatory requirements (see section 1.5).
487
488 2.4.2 Before initiating a trial, the investigator/institution should have a documented and
489 dated approval/favourable opinion from the IRB/IEC for the trial protocol, informed
490 consent material, participant recruitment procedures (e.g., advertisements) and any
491 other information to be provided to participants.
492
493 2.4.3 As part of the investigator’s/institution’s or sponsor’s (in accordance with applicable
494 regulatory requirements) submission to the IRB/IEC, a current copy of the
495 Investigator’s Brochure or basic product information brochure should be provided
496 (see section A.1.1 of Appendix A. Investigator’s Brochure). If the Investigator’s
497 Brochure is updated during the trial, the IRB/IEC should receive the current version
498 in accordance with applicable regulatory requirements.
499
500 2.4.4 As the trial progresses, the investigator/institution or sponsor should provide any
501 updates to the participant information according to applicable regulatory
502 requirements.
503
504 2.4.5 The investigator or the sponsor should submit documented summaries of the trial
505 status to the IRB/IEC in accordance with local regulatory requirements or upon
506 request.
507
508 2.4.6 The investigator or the sponsor should promptly communicate to the IRB/IEC (see
509 section 1.3.8) and, where applicable, the institution about any changes significantly
510 affecting the conduct of the trial and/or increasing the risk to participants.
511 2.5 Compliance with Protocol
512 2.5.1 The investigator should comply with the protocol and GCP and applicable regulatory
513 requirements. The investigator/institution should sign the protocol or an alternative
514 contract to confirm agreement with the sponsor.
12
515 2.5.2 The investigator should document all protocol deviations and review deviations
516 communicated to them by the sponsor. For important deviations, the investigator
517 should explain the deviation and implement appropriate measures to prevent a
518 recurrence, where applicable, see section 3.9.3.
519
520 2.5.3 The investigator should follow the protocol and deviate only where necessary to
521 eliminate an immediate hazard(s) to trial participants. In case of deviations undertaken
522 to eliminate immediate hazard to trial participants, the investigator should inform the
523 sponsor, IRB/IEC and/or regulatory authorities promptly.
524
525 2.5.4 The investigator should report information on the immediate hazard, the implemented
526 change and the subsequent proposed protocol amendment to the IRB/IEC and/or
527 regulatory authorities.
528 2.6 Premature Termination or Suspension of a Trial
529 2.6.1 If the trial is prematurely terminated or suspended for any reason, the
530 investigator/institution should promptly inform the trial participants and should assure
531 appropriate therapy and follow-up for the participants.
532
533 2.6.2 Where the investigator terminates or suspends their involvement in a trial without
534 prior agreement by the sponsor, the investigator should promptly inform the sponsor,
535 the IRB/IEC and the regulatory authorities in accordance with applicable regulatory
536 requirements and should provide a detailed explanation of the reasons.
537
538 2.6.3 If the sponsor terminates or suspends a trial, the investigator/institution, or the
539 sponsor, in accordance with applicable regulatory requirement(s), should promptly
540 inform the IRB/IEC and the regulatory authorities. See section 3.17.1.
541
542 2.6.4 If the IRB/IEC terminates or suspends its approval/favourable opinion of a trial (see
543 sections 1.1.3 and 1.3.9), the investigator should inform the institution, where
544 applicable, and the investigator/institution should promptly notify the sponsor.
545 2.7 Participant Medical Care and Safety Reporting
546 2.7.1 Medical Care of Trial Participants
547 (a) A qualified physician or, where appropriate, a qualified dentist (or other
548 qualified healthcare professionals in accordance with local regulatory
549 requirements) who is an investigator or a sub-investigator for the trial should
550 have the overall responsibility for trial-related medical care and decisions.
551
552 (b) Other appropriately qualified healthcare professionals may be involved in the
553 medical care of trial participants, in line with their normal activities and in
554 accordance with local regulatory requirements.
555
556 (c) During and following participation in a trial, the investigator/institution should
557 ensure that adequate medical care is provided to a participant for any adverse
558 events, including clinically significant laboratory values, related to the trial.
13
559 The investigator/institution should inform a participant when medical care is

560 needed for intercurrent illness(es) of which the investigator becomes aware.
561
562 (d) The investigator should inform the participant’s primary physician about the
563 participant’s involvement in the trial if the participant has a primary physician
564 and agrees to the primary physician being informed.
565 2.7.2 Safety Reporting
566 (a) Adverse events and/or laboratory abnormalities required for safety evaluations
567 (as outlined in the protocol) should be reported to the sponsor according to the
568 reporting requirements and within the time periods specified in the protocol.
569
570 (b) All serious adverse events (SAEs) should be reported immediately (after the
571 investigator reasonably becomes aware of the event) to the sponsor. In
572 accordance with applicable regulatory requirements, the protocol may identify
573 SAEs not requiring immediate reporting, for example, deaths or other events
574 that are endpoints. Subsequent information should be submitted as a follow-
575 up report, as necessary.
576
577 (c) For reported deaths, the investigator should supply the sponsor, the IRB/IEC
578 and, where applicable, the regulatory authority with any additional requested
579 information (e.g., autopsy reports and terminal medical reports) when they
580 become available.
581
582 (d) The investigator may delegate activities for safety reporting to qualified
583 investigator site staff but retains the overall responsibility for safety of
584 participants under their responsibility and compliance with the reporting
585 requirements.
586 2.8 Informed Consent of Trial Participants
587 2.8.1 In obtaining and documenting informed consent (paper or electronic format), the
588 investigator should comply with the applicable regulatory requirement(s) and should
589 adhere to GCP and to the ethical principles that have their origin in the Declaration of
590 Helsinki. See the glossary term “informed consent.” The informed consent process
591 should include the following:
592
593 (a) Prior to consenting and enrolling participants, the investigator should have the
594 IRB/IEC’s documented approval/favourable opinion of the informed consent
595 materials and process;
596
597 (b) The information should be as clear and concise as possible, use simple
598 language and avoid unnecessary volume and complexity. This is to ensure that
599 the trial participants or their legally acceptable representatives have an
600 adequate understanding of the objectives of the trial, alternative treatments,
601 the potential benefits and risks, burdens and their rights and obligations to be
602 able to make an informed decision as to their participation in the trial;
14
603 (c) Varied approaches (e.g., text, images, videos and other interactive methods)
604 may be used in the informed consent process including for providing
605 information to the participant. Obtaining consent remotely may be considered
606 where appropriate.
607
608 2.8.2 The participant or the participant’s legally acceptable representative should be
609 informed in a timely manner if new information becomes available that may be
610 relevant to the participant’s willingness to continue trial participation. The
611 communication of this information and confirmation of the willingness to continue
612 trial participation should be documented.
613
614 New information that could impact a participant’s willingness to continue
615 participation should be assessed to determine if re-consent is needed (e.g., depending
616 on the stage of the trial, consideration should be given to whether the new information
617 is relevant only to new participants or to existing participants). If re-consent is needed
618 (e.g., information on emerging safety concerns), new information should be clearly
619 identified in the revised informed consent materials. Revised informed consent
620 materials should receive the IRB/IEC’s approval/favourable opinion in advance of
621 use.
622
623 2.8.3 Neither the investigator nor the investigator site staff should coerce or unduly
624 influence a participant to participate or to continue their participation in the trial.
625
626 2.8.4 None of the information provided to the participant during the informed consent
627 process should contain any language that causes the participant or the participant’s
628 legally acceptable representative to waive or to appear to waive any legal rights, or
629 that releases or appears to release the investigator, the institution, the sponsor or their
630 service providers from liability for negligence.
631
632 2.8.5 The informed consent process should be conducted by the investigator or other
633 investigator site staff delegated by the investigator, in accordance with applicable
634 regulatory requirements. If the participant is unable to provide consent themselves,
635 the participant’s legally acceptable representative should provide their consent on
636 behalf of the participant.
637
638 2.8.6 The information provided during the informed consent process and translations should
639 be relevant, clear, simple, concise and understandable to the participant or the
640 participant’s legally acceptable representative and the impartial witness, where
641 applicable.
642
643 2.8.7 Before informed consent may be obtained, the investigator or investigator site staff
644 delegated by the investigator, in accordance with the protocol and conditions of
645 IRB/IEC favourable opinions/approvals, should provide the participant or the
646 participant’s legally acceptable representative ample time unless justified (e.g., in an
647 emergency situation) and opportunity to enquire about trial details and to decide
648 whether or not to participate in the trial. Questions about the trial should be answered
15
649 to the satisfaction of the participant or the participant’s legally acceptable

650 representative.
651
652 2.8.8 Prior to trial participation, the informed consent form should be signed and dated by
653 the participant or by the participant’s legally acceptable representative and, where
654 appropriate, impartial witness and by the investigator or delegated investigator site
655 staff who conducted the informed consent discussion. The informed consent process
656 may involve a physical signature or an electronic signature.
657
658 2.8.9 In emergency situations, when prior consent of the participant is not possible, the
659 consent of the participant’s legally acceptable representative, if present, should be
660 requested. When prior consent of the participant is not possible and the participant’s
661 legally acceptable representative is not available, enrolment of the participant should
662 require measures described in the protocol and/or elsewhere, with documented
663 approval/favourable opinion by the IRB/IEC, to protect the participant’s rights, safety
664 and well-being and to ensure compliance with applicable regulatory requirements.
665 The participant or the participant’s legally acceptable representative should be
666 informed about the trial as soon as possible, and consent as appropriate (see section
667 2.8.10) should be requested.
668
669 2.8.10 If a participant or the legally acceptable representative is unable to read, an impartial
670 witness should be present (remotely or in-person) during the entire informed consent
671 discussion. After the informed consent form and any other information is read and
672 explained to the participant or the participant’s legally acceptable representative and
673 they have orally consented to the participant’s trial participation and, if capable of
674 doing so, have signed and personally dated the informed consent form, the witness
675 should contemporaneously sign and personally date the consent form. By signing the
676 consent form, the witness attests that the consent information was accurately
677 explained to and apparently understood by the participant or the participant’s legally
678 acceptable representative and that informed consent was freely given by the
679 participant or the participant’s legally acceptable representative.
680
681 2.8.11 The informed consent discussion and the informed consent materials to be provided
682 to participants should explain the following as applicable:
683
684 (a) the purpose of the trial;
685
686 (b) that the trial involves research and summary of the experimental aspects of the
687 trial;
688
689 (c) the trial’s investigational product(s) and the probability for random
690 assignment to the investigational product, if applicable;
691
692 (d) the trial procedures to be followed including all invasive procedures;
693
694 (e) the participant’s obligations;
16
695 (f) the reasonably foreseeable risks or inconveniences to the participant and, when
696 applicable, the participant’s partner, to an embryo, foetus or nursing infant;
697
698 (g) the reasonably expected benefits. When there is no intended clinical benefit to
699 the participant, the participant should be made aware of this;
700
701 (h) the alternative procedure(s) or course(s) of treatment that may be available to
702 the participant and their important potential benefits and risks;
703
704 (i) the compensation and/or treatment available to the participant in the event of
705 trial-related injury;
706
707 (j) any anticipated prorated compensation to the participant for trial participation;
708
709 (k) any anticipated expenses to the participant for trial participation;
710
711 (l) that the participant’s trial participation is voluntary, and the participant may
712 refuse to participate or may withdraw, at any time, without penalty or loss of
713 benefits to which the participant is otherwise entitled;
714
715 (m) the process by which the participant’s data will be handled, including in the
716 event of the withdrawal of participation in accordance with regulatory
717 requirements;
718
719 (n) that by agreeing to participate in the trial, the participant or their legally
720 acceptable representative allows direct access to original medical records, per
721 applicable regulatory requirements, while safeguarding the confidentiality of
722 the participant. This access is limited for the purpose of reviewing trial
723 activities and/or reviewing or verifying data and records by the IRB/IEC(s),
724 regulatory authority(ies) and the sponsor’s representatives, for example,
725 monitor(s) or auditor(s);
726
727 (o) that records identifying the participant will be kept confidential and, to the
728 extent permitted by the applicable regulatory requirements, will not be made
729 publicly available. If the trial results are published, the participant’s identity
730 will remain confidential. The trial may be registered on publicly accessible
731 and recognised databases, per applicable regulatory requirements;
732
733 (p) that the participant or the participant’s legally acceptable representative will
734 be informed in a timely manner if information becomes available that may be
735 relevant to the participant’s willingness to continue trial participation;
736
737 (q) the person(s) to contact for further trial information and the trial participant’s
738 rights, and whom to contact in the event of suspected trial-related injury;
739
17
740 (r) the foreseeable circumstances and/or reasons under which the participant’s
741 trial participation may be terminated;
742
743 (s) the expected duration of the participant’s trial participation;
744
745 (t) the approximate number of participants involved in the trial;
746
747 (u) that trial results and information on the participant’s actual treatment, if
748 appropriate, will be made available to them should they desire it.
749
750 2.8.12 Prior to participation, the participant or the participant’s legally acceptable
751 representative should receive a copy (paper or electronic) of the signed informed
752 consent form and any other informed consent materials provided to the participants,
753 or in accordance with applicable regulatory requirements. During trial participation,
754 the participant or the participant’s legally acceptable representative should receive a
755 copy of the consent form updates and any other updated informed consent materials
756 provided to participants.
757
758 2.8.13 Where a minor is to be included as a participant, age-appropriate assent information
759 should be provided and discussed with the minor as part of the consent process, and
760 assent from the minor to enrol in the trial should be obtained as appropriate. A process
761 for re-consent should be considered if, during the course of the trial, the minor reaches
762 the age of legal consent, in accordance with applicable regulatory requirements.
763
764 2.8.14 When a clinical trial includes participants who may only be enrolled in the trial with
765 the consent of the participant’s legally acceptable representative (e.g., minors, patients
766 with severe impaired decision-making capacity), the participant should be informed
767 about the trial to the extent compatible with the participant’s understanding and, if
768 capable, the participant should sign and personally date the informed consent form or
769 assent form as appropriate.
770
771 2.8.15 In exceptional circumstances (e.g., public health emergencies), when the usual
772 methods to obtain and document informed consent are not possible, the use of
773 alternative measures and technologies in accordance with local IRBs/IECs and
774 applicable regulatory requirements should be considered.
775 2.9 End of Participation in a Clinical Trial
776 2.9.1 When a participant decides to stop treatment with the investigational product, stop
777 trial visits or completely withdraw from a trial; is discontinued from the trial; or
778 reaches routine end of trial, the investigator should follow the protocol and other
779 sponsor instructions to determine appropriate follow-up measures. This may include
780 instructions to avoid unnecessary loss of already collected critical data in accordance
781 with applicable regulatory requirements.
782
783 2.9.2 Although a participant is not obliged to provide a reason(s) for withdrawing
784 prematurely from a trial, the investigator should make a reasonable effort to ascertain
18
785 the reason(s), while fully respecting the participant’s rights. The investigator should
786 consider discussing with the participant or the participant’s legally acceptable
787 representative the reasons for withdrawal to determine if there are ways to address the
788 concerns. The investigator site staff should make an effort to explain to the participant
789 the value and importance of continuing their participation to minimise trial
790 participants withdrawal.
791
792 2.9.3 Where relevant, the investigator should inform the participant about the trial results
793 and treatment received when this information is available from the sponsor after
794 unblinding, with due respect to the participant’s preference to be informed.
795 2.10 Investigational Product Management
796 2.10.1 Responsibility for investigational product(s) accountability rests with the
797 investigator/institution. The sponsor may facilitate this process.
798
799 2.10.2 When the investigator/institution assigns some or all of their activities for
800 investigational product(s) accountability to a pharmacist or another individual, they
801 should be under the supervision of the investigator/institution.
802
803 2.10.3 The investigator/institution and/or a pharmacist or other appropriate individual should
804 maintain records of the product’s delivery, the inventory, the use by each participant
805 (including documenting that the participants were provided the doses specified by the
806 protocol) and the return to the sponsor and destruction or alternative disposition of
807 unused product(s). These records should include dates, quantities, batch/serial
808 numbers, expiration dates (if applicable) and the unique code numbers assigned to the
809 investigational product(s) and trial participants. For authorised medicinal products,
810 alternative approaches to the aforementioned may be considered, in accordance with
811 local regulatory requirements.
812
813 2.10.4 The investigational product(s) should be stored as specified by the sponsor and in
814 accordance with applicable regulatory requirement(s).
815
816 2.10.5 The investigator should ensure that the investigational product(s) are used only in
817 accordance with the approved protocol.
818
819 2.10.6 Where applicable, the investigator or a person designated by the
820 investigator/institution should explain the correct use of the investigational product(s)
821 to each participant and should check, at intervals appropriate for the trial, that each
822 participant is following the instructions properly.
823 2.11 Randomisation Procedures and Unblinding
824 The investigator should follow the trial’s randomisation procedures, if any, and, in the case of
825 an investigator-blinded trial, should ensure that the identification code is broken only in
826 accordance with the protocol. In the case of an emergency, to protect patient safety, the
827 investigator should be prepared and capable from the start of the trial to perform unblinding
828 without undue delay and hinderance. The investigator should promptly document and explain
19
829 to the sponsor any premature unblinding (e.g., accidental unblinding, emergency unblinding to
830 protect trial participant, unblinding due to an SAE) of the investigational product(s).
831 2.12 Records
832 2.12.1 In generating, recording and reporting trial data, the investigator should ensure the
833 integrity of data under their responsibility, irrespective of the media used.
834
835 2.12.2 The investigator/institution should maintain adequate source records that include
836 pertinent observations on each of the trial participants under their responsibility.
837 Source records should be attributable, legible, contemporaneous, original, accurate
838 and complete. Changes to source records should be traceable, should not obscure the
839 original entry and should be explained if necessary (via an audit trail). The
840 investigator should define what is considered to be a source record(s), the methods of
841 data capture and their location prior to starting the trial and should update this
842 definition when needed. Unnecessary transcription steps in between the source record
843 and the data acquisition tool should be avoided.
844
845 2.12.3 The investigator should have timely access to and be responsible for the timely review
846 of data, including relevant data from external sources (e.g., central laboratory data,
847 centrally read imaging data, other institution’s records and, if appropriate, electronic
848 patient-reported outcome (ePRO) data) which can have an impact on, for example,
849 participant eligibility, treatment or safety. The protocol may provide exceptions for
850 access, for instance, to protect blinding.
851
852 2.12.4 The investigator should ensure that data acquisition tools and other systems deployed
853 by the sponsor for clinical trial purposes are used as specified in the protocol or trial-
854 related instructions.
855
856 2.12.5 The investigator should ensure the accuracy, completeness, legibility and timeliness
857 of the data reported to the sponsor in the data acquisition tools completed by the
858 investigator site (e.g., case report form (CRF)) and in all required reports. The
859 investigator should review and endorse the reported data at milestones agreed upon
860 with the sponsor (e.g., interim analysis).
861
862 2.12.6 Data reported to the sponsor should be consistent with the source records or the
863 discrepancies explained. Changes or corrections in the reported data should be
864 traceable, should be explained (if necessary) and should not obscure the original entry.
865
866 2.12.7 The investigator/institution should implement appropriate measures to protect the
867 privacy and confidentiality of personal information of trial participants in accordance
868 with applicable regulatory requirements on personal data protection. Data reported to
869 the sponsor should be identified by an unambiguous participant code that can be traced
870 back to the identity of the participant by the investigator/institution.
871
872 2.12.8 For systems deployed by the investigator/institution that maintain and retain trial
873 data/information, the investigator/institution should ensure that such data are
20
874 protected from unauthorised access, disclosure, dissemination or alteration and from
875 inappropriate destruction or accidental loss.
876
877 2.12.9 When using computerised systems in a clinical trial, the investigator/institution should
878 do the following:
879
880 (a) for systems deployed by the investigator/institution, ensure that appropriate
881 individuals have secure and attributable access;
882
883 (b) for systems deployed by the investigator/institution specifically for the
884 purposes of clinical trials, ensure that the requirements for computerised
885 systems in section 4 are addressed;
886
887 (c) where equipment for data acquisition is provided to trial participants by the
888 investigator, ensure that traceability is maintained and participants are
889 provided with appropriate training;
890
891 (d) ensure that incidents in the use and operation of computerised systems, which
892 in their judgement may have a significant and/or persistent impact on the trial
893 data, are reported to the sponsor and, where applicable, to the IRB/IEC.
894
895 2.12.10 The investigator/institution should maintain the trial records as specified in Appendix
896 C. Essential Records for the Conduct of a Clinical Trial and as required by the
897 applicable regulatory requirement(s). The investigator/institution should have control
898 of all essential records generated by the investigator/institution before, during and
899 after the trial. The investigator/institution should take measures to prevent accidental
900 or premature destruction of these records. If the investigator closes a site or leaves a
901 site during or after the end of the clinical trial, the sponsor should be notified of the
902 appropriate individual responsible for retention of the site’s essential records.
903
904 2.12.11 The investigator/institution should retain the essential records for the required
905 retention period in accordance with applicable regulatory requirements or until the
906 sponsor informs the investigator/institution that these records are no longer needed,
907 whichever is the longer (see Appendix C).
908
909 2.12.12 Upon request of the monitor, auditor, IRB/IEC or regulatory authority, the
910 investigator/institution should make available for direct access all requested trial-
911 related records.
912 2.13 Clinical Trial/Study Reports
913 2.13.1 Upon completion of the trial, the investigator, where applicable, should inform the
914 institution. The investigator/institution should provide the IRB/IEC with a summary
915 of the trial’s outcome and, if applicable, the regulatory authority(ies) with any
916 required reports.
917
21
918 2.13.2 Where a coordinating investigator is involved in a trial, consideration should be given
919 to them being a signatory on the clinical trial report; see ICH E3 Structure and Content
920 of Clinical Study Reports.
921
922 3. SPONSOR
923 The responsibility of the sponsor entails the implementation of risk-proportionate processes to
924 ensure the safety of the trial participants and the reliability of the trial results throughout the
925 clinical trial life cycle.
926 3.1 Trial Design
927 3.1.1 When planning trials, the sponsor should ensure that sufficient safety and efficacy
928 data from nonclinical studies and/or clinical trials and/or real-world data are available
929 to support human exposure by the route, at the dosages, for the duration and in the
930 trial population to be studied.
931
932 3.1.2 Sponsors should incorporate quality into the design of the clinical trial by identifying
933 factors that are critical to the quality of the trial and by managing risks to those factors.
934
935 3.1.3 Sponsors should consider inputs from a wide variety of stakeholders, for example,
936 healthcare professionals and patients, to support the development plan and clinical
937 trial protocols as described in ICH E8(R1) and when developing the informed consent
938 material and any other participant-facing information.
939
940 3.1.4 The sponsor should ensure that all aspects of the trial are operationally feasible and
941 should avoid unnecessary complexity, procedures and data collection. Protocols, data
942 acquisition tools and other operational documents should be fit for purpose, clear,
943 concise and consistent, when applicable.
944 3.2 Resources
945 The sponsor should ensure that sufficient resources are available to appropriately conduct the
946 trial.
947 3.3 Allocation of Activities
948 Prior to initiating clinical trial activities, the sponsor should determine the roles and allocate
949 trial-related activities accordingly.
950 3.4 Qualification and Training
951 The sponsor should utilise appropriately qualified individuals for the activities to which they
952 are assigned (e.g., biostatisticians, clinical pharmacologists, physicians, data scientists/data
953 managers, auditors and monitors) throughout the trial process.
954 3.4.1 Medical Expertise
955 The sponsor should have medical personnel readily available who will be able to
956 advise on specific trial-related medical questions or problems.
22
957 3.5 Financing

958 The financial aspects of the trial should be documented in an agreement between the sponsor
959 and the investigator/institution.
960 3.6 Agreements
961 3.6.1 Agreements made by the sponsor with the investigator/institution, service providers
962 and any other parties (e.g., independent data monitoring committee (IDMC),
963 adjudication committee) involved with the clinical trial should be documented prior
964 to initiating the activities.
965
966 3.6.2 Agreements should be updated when necessary to reflect significant changes in the
967 activities delegated.
968
969 3.6.3 The sponsor should obtain the investigator’s/institution’s and, where applicable,
970 service provider’s agreement:
971
972 (a) to conduct the trial in accordance with the approved protocol and in
973 compliance with GCP and applicable regulatory requirement(s);
974
975 (b) to comply with procedures for data recording/reporting;
976
977 (c) to retain the trial-related essential records for the required retention period in
978 accordance with applicable regulatory requirements or until the sponsor
979 informs the investigator/institution or, where applicable, the service provider,
980 that these documents are no longer needed, whichever is longer;
981
982 (d) to permit monitoring, auditing and inspections by sponsors, IRB/IECs and
983 regulatory authorities (domestic and foreign) including providing direct access
984 to source records and facilities, including to those of service providers.
985
986 3.6.4 The responsibilities of coordinating investigator(s) and the other participating
987 investigators should be documented prior to the start of the trial.
988
989 3.6.5 Any of the sponsor’s trial-related activities that are transferred to and assumed by a
990 service provider should be documented in an agreement. The sponsor’s trial-related
991 activities that are not specifically transferred to and assumed by a service provider are
992 retained by the sponsor.
993
994 3.6.6 The sponsor should provide information to the investigator on any service provider
995 identified by the sponsor to undertake any activities under the responsibility of the
996 investigator. The responsibility for such activities remains with the investigator.
997
998 3.6.7 A sponsor may transfer any or all of the sponsor’s trial-related activities to a service
999 provider; however, the ultimate responsibility for the sponsor’s trial-related activities,
1000 including protection of participants’ rights, safety and well-being and reliability of the
1001 trial data, resides with the sponsor. Any service provider used for clinical trial
23
1002 activities should implement appropriate quality management and report to the sponsor
1003 any incidents that might have an impact on the safety of trial participants or/and trial
1004 results.
1005
1006 3.6.8 The sponsor is responsible for assessing the suitability of and selecting the service
1007 provider to ensure that they can adequately undertake the activities transferred to
1008 them. The sponsor should provide the service providers with the protocol where
1009 necessary as well as any other documents required for them to perform their activities.
1010
1011 3.6.9 The sponsor should have access to relevant information (e.g., SOPs and performance
1012 metrics) for selection and oversight of service providers.
1013
1014 3.6.10 The sponsor should ensure appropriate oversight of important trial-related activities
1015 that are transferred to service providers and further subcontracted.
1016
1017 3.6.11 Trial-related activities performed by service providers should be conducted in
1018 accordance with relevant GCP requirements, which may be fulfilled by a service
1019 provider’s existing processes.
1020
1021 3.6.12 A clinical trial may have one or several sponsors where permitted under applicable
1022 regulatory requirements. In trials with more than one sponsor, the sponsors should
1023 have a documented agreement that sets out their respective responsibilities, in
1024 accordance with local regulatory requirements and/or practice. Where the documented
1025 agreement does not specify to which sponsor a given responsibility is attributed, that
1026 responsibility lies with all sponsors.
1027 3.7 Investigator Selection
1028 3.7.1 The sponsor is responsible for selecting the investigator(s)/institution(s). Each
1029 investigator should be qualified by education, training and experience and should
1030 demonstrate they have adequate resources and facilities to properly conduct the trial.
1031 If organisation of a coordinating committee and/or selection of coordinating
1032 investigator(s) are to be utilised in multicentre trials, their organisation and/or
1033 selection are the sponsor’s responsibility, and their roles should be documented prior
1034 to their involvement in the trial.
1035
1036 3.7.2 The sponsor should provide the investigator(s)/institution(s) with the protocol and an
1037 up-to-date Investigator’s Brochure as well as sufficient time for the review of the
1038 protocol and the information provided.
1039 3.8 Communication with IRB/IEC and Regulatory Authority(ies)
1040 3.8.1 Notification/Submission to Regulatory Authority(ies)
1041 In accordance with applicable regulatory requirement(s), before initiating the clinical
1042 trial(s), the sponsor (or the sponsor and the investigator) should submit any required
1043 application(s) to the appropriate regulatory authority(ies) for review, acceptance
1044 and/or permission to begin the trial(s). Any notification/submission should be dated
1045 and contain sufficient information to identify the protocol.
24
1046 3.8.2 Confirmation of Review by IRB/IEC

1047 (a) Where reference is made to a submission to the IRB/IEC, this can be made by
1048 the investigator/institution or sponsor in accordance with applicable regulatory
1049 requirements (see section 1.5).
1050
1051 (b) The sponsor should ensure that the following is obtained:
1052
1053 (i) The name and address of the relevant IRB/IEC along with:
1054
1055 (aa) a statement that it is organised and operates according to GCP
1056 and the applicable regulatory requirements;
1057
1058 (bb) documented initial and subsequent IRB/IEC
1059 approval/favourable opinion as well as any termination of the
1060 trial or the suspension of approval/favourable opinion.
1061 3.9 Sponsor Oversight
1062 3.9.1 The sponsor should ensure that the trial design and trial conduct, the processes
1063 undertaken, and the information and data generated are of sufficient quality to ensure
1064 reliable trial results, trial participant’s safety and appropriate decision making.
1065
1066 3.9.2 The sponsor should ensure that trial processes are conducted in compliance with the
1067 trial protocol and related documents as well as with applicable regulatory
1068 requirements and ethical standards.
1069
1070 3.9.3 The sponsor should determine necessary trial-specific criteria for classifying protocol
1071 deviations as important (i.e., those that impact the rights, safety and well-being of trial
1072 participants and the reliability of results).
1073
1074 3.9.4 Decisions related to the trial should be appropriately assessed for their impact on
1075 participant’s rights, safety and well-being and the reliability of trial results. Risks
1076 related to such decisions should be suitably managed throughout the planning,
1077 conduct and reporting of the trial.
1078
1079 3.9.5 The range and extent of oversight measures should be fit for purpose and tailored to
1080 the complexity of and risks associated with the trial. The selection and oversight of
1081 investigators and service providers are fundamental features of the oversight process.
1082 Oversight by the sponsor includes quality assurance and quality control processes
1083 relating to the trial-related activities of investigators and service providers.
1084
1085 3.9.6 The sponsor should ensure appropriate and timely escalation and follow-up of issues
1086 to allow the implementation of appropriate actions in a timely manner.
1087
1088 3.9.7 The sponsor may consider establishing an IDMC to assess the progress of a clinical
1089 trial including the safety data and the efficacy endpoints at intervals and to recommend
1090 to the sponsor whether to continue, modify or stop a trial.
25
1091 3.9.8 Where appropriate, sponsors may also establish an endpoint assessment/adjudication
1092 committee in certain trials to review important endpoints reported by investigators to
1093 determine whether the endpoints meet protocol-specified criteria. Such committees
1094 should typically be blinded to the assigned treatments when performing their
1095 assessments, regardless of whether the trial itself is conducted in a blinded manner, to
1096 ensure that the data reviewed by committee are as free of bias as possible.
1097
1098 3.9.9 Committees established for purposes that could impact participant safety or the
1099 reliability of trial results should include members with relevant expertise and with
1100 managed conflicts of interest, have written operating procedures (e.g., charters) and
1101 document their decisions.
1102 3.10 Quality Management
1103 The sponsor should implement an appropriate system to manage quality throughout all stages
1104 of the trial process. Quality management includes the design and implementation of efficient
1105 clinical trial protocols including tools and procedures for trial conduct (including for data
1106 collection and management) in order to support participant’s rights, safety and well-being and
1107 the reliability of trial results. The sponsor should adopt a proportionate and risk-based approach
1108 to quality management, which involves incorporating quality into the design of the clinical trial
1109 (i.e., quality by design) and identifying those factors that are likely to have a meaningful impact
1110 on participant’s rights, safety and well-being and the reliability of the results (i.e., critical to
1111 quality factors as described in ICH E8(R1)). The sponsor should describe the quality
1112 management approach implemented in the trial in the clinical trial report (see ICH E3).
1113 3.10.1 Risk Management
1114 A proportionate approach to the identification and management of risk is described below:
1115 3.10.1.1 Risk Identification
1116 The sponsor should identify risks that may have a meaningful impact on critical to
1117 quality factors. Risks should be considered across the processes used in the clinical
1118 trial (e.g., patient selection, informed consent process, randomisation and
1119 investigational product administration, data handling, and service provider activities).
1120 3.10.1.2 Risk Evaluation
1121 The sponsor should evaluate potential risks by considering:
1122 (a) the likelihood of harm/hazard occurring;
1123
1124 (b) the extent to which such harm/hazard would be detectable;
1125
1126 (c) the impact of such harm/hazard on trial participant protection and the
1127 reliability of trial results.
1128 3.10.1.3 Risk Control
1129 (a) Risk control should be proportionate to the importance of the risk to
1130 participants’ rights, safety and well-being and the reliability of trial results.
26
1131 Risk mitigation activities may be incorporated in protocol design and

1132 implementation, monitoring plans, agreements between parties defining roles
1133 and responsibilities, systematic safeguards to ensure adherence to SOPs, and
1134 training in processes and procedures.
1135
1136 (b) The sponsor should set acceptable ranges to support this process within which
1137 variation can be accepted. Where deviation beyond these ranges is detected,
1138 an evaluation should be performed to determine if there is a possible systemic
1139 issue and if action is needed.
1140 3.10.1.4 Risk Communication
1141 The sponsor should communicate the identified risks and mitigating activities, if
1142 applicable, to those who are involved in taking action or are affected by such activities.
1143 Communication also facilitates risk review and continual improvement during clinical
1144 trial conduct.
1145 3.10.1.5 Risk Review
1146 The sponsor should periodically review risk control measures to ascertain whether the
1147 implemented quality management activities remain effective and relevant, taking into
1148 account emerging knowledge and experience.
1149 3.10.1.6 Risk Reporting
1150 The sponsor should summarise and report the risks and the remedial actions taken in
1151 relation to important deviations from the acceptable ranges as detailed in section
1152 3.10.1.3(b) and document them in the clinical trial report (ICH E3).
1153 3.11 Quality Assurance and Quality Control
1154 The sponsor is responsible for establishing, implementing and maintaining
1155 appropriate quality assurance and quality control processes and documented
1156 procedures to ensure that trials are conducted and data are generated, recorded and
1157 reported in compliance with the protocol, GCP and the applicable regulatory
1158 requirement(s).
1159 3.11.1 Quality Assurance
1160 Quality assurance should be applied throughout the clinical trial and includes
1161 implementing strategies to identify potential or actual causes of serious non-
1162 compliance with the protocol, GCP and/or applicable regulatory requirements to
1163 enable their corrective and/or preventive actions.
1164 3.11.2 Audit
1165 When performed, audits should be conducted in a manner that is proportionate to the
1166 risks associated with the conduct of the trial.
1167 The purpose of a sponsor’s audit, which is independent of and separate from routine
1168 monitoring or quality control functions, is to evaluate whether the processes put in
1169 place to manage and conduct the trial are effective and compliant.
27
1170 3.11.2.1 Selection and Qualification of Auditors

1171 (a) The sponsor should appoint individuals who are independent of the clinical
1172 trial being audited.
1173
1174 (b) The sponsor should ensure that the auditors are qualified by training and
1175 experience to conduct audits properly.
1176 3.11.2.2 Auditing Procedures
1177 (a) The sponsor should ensure that the auditing of clinical trials/processes is
1178 conducted in accordance with the sponsor’s documented procedures on what
1179 to audit, how to audit (i.e., on-site or remote), the frequency of audits and the
1180 form and content of audit reports.
1181
1182 (b) The sponsor’s audit plan, program and procedures for a trial audit should be
1183 guided by the importance of the trial to submissions to regulatory authorities,
1184 the number of participants in the trial, the type and complexity of the trial, the
1185 level of risks to the trial participants and any identified problem(s).
1186
1187 (c) The observations and findings of the auditor(s) should be documented.
1188
1189 (d) To preserve the independence and value of the audit function, the regulatory
1190 authority(ies) should not routinely request the audit reports. Regulatory
1191 authority(ies) may seek access to an audit report on a case-by-case basis when
1192 evidence of serious GCP non-compliance exists or in the course of legal
1193 proceedings.
1194
1195 (e) When required by applicable regulatory requirements, the sponsor should
1196 provide an audit certificate.
1197 3.11.3 Quality Control
1198 Quality control should be applied to each stage of the data handling to ensure that data
1199 are reliable and have been processed correctly. Within clinical trials, monitoring and
1200 data management processes are the main quality control activities.
1201
1202 The quality control of sites (other than investigator sites, such as centralised imaging
1203 reading facilities), including on site and/or centralised activities, may be undertaken
1204 and reported using a risk-based approach.
1205 3.11.4 Monitoring
1206 The aim of monitoring is to ensure the participants’ rights, safety and well-being and
1207 the reliability of trial results as the trial progresses. Monitoring is one of the principal
1208 quality control activities.
1209 Monitoring involves a broad range of activities including, but not limited to,
1210 communication with investigator sites, verification of the investigator and investigator
1211 site staff qualifications and site resources, training and review of trial documents and
28
1212 information using a range of approaches including source data review, source data
1213 verification, data analytics and visits to institutional facilities undertaking trial-related
1214 activities. Some of these monitoring activities may be conducted by different methods
1215 and persons with different roles. However, monitoring should be performed by
1216 persons not involved in the clinical conduct of the trial being monitored. The
1217 monitoring approach should consider the activities and services involved, including
1218 decentralised settings, and be included in the monitoring plan. Monitors and other trial
1219 staff should adhere to data protection and confidentiality requirements in accordance
1220 with applicable regulatory requirements, institution policy and established data
1221 security standards.
1222 Monitoring activities may include site monitoring (performed on-site or remotely) and
1223 centralised monitoring, depending on the monitoring strategy and the design of the
1224 clinical trial.
1225 The sponsor should determine the appropriate extent and nature of monitoring, based
1226 on identified risks. Factors such as the objective, purpose, design, complexity,
1227 blinding, number of trial participants, investigational product, current knowledge of
1228 the safety profile and endpoints of the trial should be considered.
1229 3.11.4.1 Investigator Site Monitoring
1230 (a) Monitoring may be performed in relation to the clinical trial activities at the
1231 investigator sites (e.g., including their pharmacies and local laboratories, as
1232 appropriate). The frequency of monitoring activities should also be determined
1233 based on identified risks. Monitoring activities and their frequency should be
1234 modified as appropriate using knowledge gained.
1235
1236 (b) This monitoring activity may be performed on-site or remotely depending on
1237 the nature of the activity and its objectives.
1238
1239 (c) Monitoring may include secure, remote, direct read-only access to source
1240 records, other data acquisition tools and essential record retention systems.
1241 3.11.4.2 Centralised Monitoring
1242 (a) Centralised monitoring is an evaluation of accumulated data, performed in a
1243 timely manner, by the sponsor’s qualified and trained persons (e.g., medical
1244 monitor, data scientist/data manager, biostatistician).
1245
1246 (b) Centralised monitoring processes provide additional monitoring capabilities
1247 that can complement and reduce the extent and/or frequency of site monitoring
1248 or be used on its own. Use of centralised data analytics can help identify
1249 systemic or site-specific issues, including protocol non-compliance and
1250 potentially unreliable data.
1251
1252 (c) Centralised monitoring may support the selection of sites and/or processes for
1253 targeted site monitoring.
29
1254 3.11.4.3 Monitoring Plan

1255 The sponsor should develop a monitoring plan that is tailored to the identified
1256 potential safety risks, the risks to data quality and/or other risks to the reliability of
1257 the trial results. Particular attention should be given to procedures relevant to
1258 participant safety and to trial endpoints. The plan should describe the monitoring
1259 strategy, the monitoring activities of all the parties involved, the various monitoring
1260 methods and tools to be used, and the rationale for their use. The monitoring strategy
1261 should ensure appropriate oversight of trial conduct and consider site capabilities and
1262 the potential burden. The plan should focus on aspects that are critical to quality. The
1263 monitoring plan should reference the sponsor’s applicable policies and procedures.
1264 Monitoring of key data and processes (e.g., those related to primary endpoints and key
1265 secondary endpoints and processes intended to assure patient safety) performed
1266 outside the investigator site (e.g., central reading facilities, central laboratories) should
1267 be addressed in the monitoring plan.
1268 3.11.4.4 Monitoring Procedures
1269 Persons performing monitoring should follow the sponsor’s monitoring plan and
1270 applicable monitoring procedures.
1271 3.11.4.5 Monitoring Activities
1272 Monitoring in accordance with the sponsor’s requirements and monitoring plan
1273 should generally include the following activities across the clinical trial life cycle, as
1274 applicable.
1275 3.11.4.5.1 Communication with Parties Conducting the Trial
1276 (a) Establishing and maintaining a line of communication between the
1277 sponsor and the investigator and other parties and individuals involved
1278 in the trial conduct (e.g., centrally performed activities). In general, each
1279 site should have an assigned monitor as their contact point.
1280
1281 (b) Informing the investigator or other parties and individuals involved in
1282 the trial conduct of identified deviations from the protocol, GCP and the
1283 applicable regulatory requirements and taking appropriate action
1284 designed to prevent recurrence of the detected deviations. Important
1285 deviations should be highlighted and should be the focus of remediation
1286 efforts as appropriate.
1287
1288 (c) Informing the investigator or other parties and individuals involved in
1289 the trial conduct of source record(s) or entry errors or omissions in data
1290 acquisition tools and ensuring that corrections, additions or deletions are
1291 made as appropriate, dated, explained (if necessary) and that approval
1292 of the change is properly documented.
1293
1294 (d) Actions taken in relation to the deviations, errors or omissions should be
1295 proportionate to their importance.
30
1296 3.11.4.5.2 Investigator Site Selection, Initiation, Management and Close-out

1297 (a) Selecting the site and confirming that the investigator and individuals or
1298 parties involved in the trial conduct have adequate qualifications,
1299 resources (see sections 3.1, 3.2, and 4.7) and facilities, including
1300 laboratories, equipment and investigator site staff, to safely and properly
1301 conduct the trial.
1302
1303 (b) Confirming that the investigator, investigator site staff and other parties,
1304 and individuals involved in the trial conduct are adequately informed
1305 about the trial and follow the current approved protocol and other
1306 protocol-related documents, such as the current Investigator’s Brochure
1307 and relevant information related to the investigational product and
1308 instructions related to their delegated activities.
1309
1310 (c) Confirming that the investigator is maintaining the essential records (see
1311 Appendix C).
1312
1313 (d) Confirming that informed consent was obtained before participation in
1314 the trial (see section 2.8) for all enrolled participants at the site.
1315
1316 (e) Determining whether adverse events are appropriately reported within
1317 the time periods required by the protocol, GCP and the applicable
1318 regulatory requirement(s).
1319
1320 (f) Clarifying the sponsor’s protocol requirements for source records and
1321 the site’s location of such data.
1322
1323 (g) Verifying that the blinding is maintained, where applicable.
1324
1325 (h) Reviewing and reporting the participant recruitment and retention rates.
1326
1327 (i) Confirming that the investigator provides the required reports,
1328 notifications or other information in accordance with the protocol and
1329 trial procedures.
1330
1331 (j) Confirming the arrangement for the retention of the essential records and
1332 the final accountability of the investigational product (e.g., return and
1333 destruction or alternative disposition, if appropriate) during site close-
1334 out activity.
1335 3.11.4.5.3 Monitoring of Investigational Product Management
1336 (a) Confirming, for the investigational product(s):
1337
1338 (i) that storage conditions are acceptable and in accordance with the
1339 storage requirement specified in the protocol;
1340
31
1341 (ii) that supplies are sufficient throughout the trial and are used
1342 within their shelf-life;
1343
1344 (iii) that the correct investigational product(s) are supplied only to
1345 participants who are eligible to receive it at the protocol-
1346 specified dose(s) and, where appropriate, in accordance with the
1347 randomisation procedures;
1348
1349 (iv) that the participants, investigator, investigator site staff and other
1350 relevant parties and individuals involved in the trial conduct are
1351 provided with necessary instruction on properly using, handling,
1352 storing, returning and destroying, or alternative disposition of the
1353 investigational product(s);
1354
1355 (v) that the receipt, use, return and destruction, or alternative
1356 disposition of the investigational product(s) are controlled and
1357 documented adequately;
1358
1359 (vi) that the disposition of unused investigational product(s)
1360 complies with applicable regulatory requirement(s) and is in
1361 accordance with the sponsor requirements;
1362
1363 (vii) where product available on the market is dispensed and used in
1364 accordance with applicable regulatory requirements, some of the
1365 previously outlined considerations may not be applicable.
1366 3.11.4.5.4 Monitoring of Clinical Trial Data
1367 (a) Verifying that the investigator is enrolling only eligible trial participants.
1368
1369 (b) Checking the accuracy, completeness and consistency of the reported
1370 trial data against the source records and other trial-related records and
1371 whether these were reported in a timely manner. This can be done on the
1372 basis of using samples and supported by data analytics, as appropriate.
1373 The sample size may need adjustment based on previous monitoring
1374 results or other indications of insufficient data quality. Monitoring
1375 should:
1376
1377 (i) verify that the data required by the protocol and identified as
1378 critical in the monitoring plan are consistent with the source;
1379
1380 (ii) identify missing data, inconsistent data, data outliers,
1381 unexpected lack of variability and protocol deviations;
1382
1383 (iii) examine data trends, such as the range, consistency and
1384 variability of data within and across sites;
1385
32
1386 (c) Identifying significant errors in data collection and reporting at a site or
1387 across sites, potential data manipulation and data integrity problems.
1388 3.11.4.6 Monitoring Report
1389 (a) Reports of monitoring activities should include a summary of what was
1390 reviewed, a description of significant findings, conclusions and actions
1391 required to resolve them and follow-up on their resolution including those not
1392 resolved in previous reports. The requirements of monitoring reports
1393 (including their content and frequency) should be described in the sponsor’s
1394 procedures.
1395
1396 (b) Reports of investigator site and/or centralised monitoring should be provided
1397 to the appropriate sponsor staff as described in the sponsor’s procedures in a
1398 timely manner for review and follow-up.
1399
1400 (c) When needed, the report should describe findings requiring escalation for
1401 action and resolution. The sponsor should decide on the appropriate action to
1402 be taken, and these decisions and the resolution of the actions involved, where
1403 needed, should be recorded.
1404 3.12 Noncompliance
1405 3.12.1 Noncompliance with the protocol, SOPs, GCP and/or applicable regulatory
1406 requirement(s) by an investigator/institution or by member(s) of the sponsor’s staff
1407 should lead to appropriate and proportionate action by the sponsor to secure
1408 compliance.
1409
1410 3.12.2 If noncompliance that significantly affects or has the potential to significantly affect
1411 trial participant’s rights, safety or well-being or the reliability of trial results is
1412 discovered, the sponsor should perform a root cause analysis, implement appropriate
1413 corrective and preventive actions and confirm their adequacy unless otherwise
1414 justified. Where the sponsor identifies issues that could significantly impact
1415 participant’s rights, safety and well-being or the reliability of trial results, the sponsor
1416 should notify the regulatory authority and/or IRB/IEC in line with applicable
1417 regulatory requirements.
1418
1419 3.12.3 If the monitoring and/or auditing identifies serious noncompliance on the part of an
1420 investigator/institution that persists despite efforts at remediation, the sponsor should
1421 terminate the investigator’s/institution’s participation in the trial. When an
1422 investigator’s/institution’s participation is terminated because of noncompliance, the
1423 sponsor should promptly notify the regulatory authority(ies) and IRB/IEC as
1424 appropriate.
1425 3.13 Safety Assessment and Reporting
1426 The sponsor is responsible for the ongoing safety evaluation of the investigational product(s).
33
1427 The Investigator’s Brochure or, where applicable, the current scientific information such as a
1428 basic product information brochure, forms the basis of safety assessment and reporting for the
1429 clinical trial. For further information, see Appendix A.
1430 3.13.1 Sponsor Review of Safety Information
1431 The sponsor should aggregate, as appropriate, and periodically review relevant safety
1432 information. This may result in the update of the protocol, Investigator’s Brochure,
1433 informed consent materials and related documents.
1434 The sponsor should review the available emerging safety information to assess
1435 whether there is any new data that may affect the participant’s willingness to continue
1436 in the trial, impact the conduct of the trial, or alter the approval/favourable opinion of
1437 the IRB/IEC and/or regulatory authority(ies), as applicable. Any information of this
1438 nature should be communicated to the participants, investigator, IRB/IEC and
1439 regulatory authorities, as applicable, in a timely manner.
1440 3.13.2 Safety Reporting
1441 (a) The sponsor should submit to the regulatory authority(ies) safety updates and
1442 periodic reports, including changes to the Investigator’s Brochure, as required
1443 by applicable regulatory requirements.
1444
1445 (b) The sponsor should, in accordance with the applicable regulatory
1446 requirement(s) and with ICH E2A Clinical Safety Data Management:
1447 Definitions and Standards for Expedited Reporting, expedite the reporting to
1448 the regulatory authority(ies) of all adverse drug reactions (ADRs) that meet
1449 three criteria: suspected, unexpected and serious (i.e., SUSARs).
1450
1451 (c) Safety reporting to regulatory authorities should be undertaken by assessing
1452 the expectedness of the reaction in relation to the applicable product
1453 information (e.g., the reference safety information (RSI) contained within the
1454 Investigator’s Brochure or alternative documents) in accordance with
1455 applicable regulatory requirements. Refer to ICH E2F Development Safety
1456 Update Report for more information about RSI.
1457
1458 (d) The reporting of SUSARs to investigator(s)/institutions(s) and to the
1459 IRB(s)/IEC(s) should be undertaken in a manner that reflects the urgency of
1460 action required and should take into consideration the evolving knowledge of
1461 the safety profile of the product. Reporting of SUSARs to the
1462 investigators/institutions should be made in accordance with regulatory
1463 requirements. In some regions, periodic reporting of line listings with an
1464 overall safety assessment may be appropriate.
1465
1466 (e) Urgent safety issues requiring immediate attention or action should be
1467 reported to the IRB/IEC and/or regulatory authority(ies) and investigators
1468 without undue delay and as specified in regulatory requirements.
1469
34
1470 (f) Alternative arrangements for safety reporting to regulatory authorities,

1471 IRBs/IECs, and investigators and for reporting by investigators to the sponsor
1472 should be prospectively agreed upon with the regulatory authority(ies) and the
1473 IRB/IEC if applicable, and described in the clinical trial protocol, (e.g., SAEs
1474 considered efficacy or safety endpoints, which would not be subject to
1475 unblinding and expedited reporting; see ICH E2A). See ICH E19.
1476 3.13.3 Managing an Immediate Hazard
1477 The sponsor should take prompt action to address immediate hazards to participants.
1478 The sponsor should determine the causes of the hazard and based on this, take
1479 appropriate remedial actions.
1480 The sponsor should consider whether the protocol requires amendment in response to
1481 an immediate hazard. The information on the immediate hazard, if required, and any
1482 subsequent protocol amendment should be submitted to the IRB/IEC and/or
1483 regulatory authorities by the investigator/institution or sponsor (in accordance with
1484 applicable regulatory requirements).
1485 3.14 Insurance/Indemnification/Compensation to Participants and Investigators
1486 3.14.1 If required by the applicable regulatory requirement(s), the sponsor should provide
1487 insurance or should indemnify (legal and financial coverage) the investigator/the
1488 institution against claims arising from the trial except for claims that arise from
1489 malpractice and/or negligence.
1490
1491 3.14.2 The sponsor’s policies and procedures should address the costs of treatment of trial
1492 participants in the event of trial-related injuries in accordance with the applicable
1494
1495 3.14.3 The approach to compensating trial participants should comply with applicable
1497 3.15 Investigational Product(s)
1498 3.15.1 Information on Investigational Product(s)
1499
1500 The sponsor should ensure that an Investigator’s Brochure is developed and updated
1501 as significant new information on the investigational product becomes available.
1502 Alternatively, for authorised medicinal products, the sponsor should identify the basic
1503 product information to be used in the trial (see Appendix A).
1504 3.15.2 Manufacturing, Packaging, Labelling and Coding Investigational Product(s)
1505 (a) The sponsor should ensure that the investigational product(s) (including active
1506 control(s) and placebo, if applicable) is characterised as appropriate to the
1507 stage of development of the product(s), is manufactured in accordance with
1508 any applicable GMP and is coded and labelled in a manner that protects the
1509 blinding, if applicable. In addition, the labelling should comply with
1510 applicable regulatory requirement(s).
1511
35
1512 (b) The sponsor should determine acceptable storage temperatures and other
1513 storage conditions (e.g., protection from light) for the investigational
1514 product(s), appropriate reconstitution fluids and procedures, and devices for
1515 product infusion, if any. The sponsor should inform all involved parties (e.g.,
1516 monitors, investigators, pharmacists, storage managers) of these
1517 determinations.
1518
1519 (c) The investigational product(s) should be packaged to prevent contamination
1520 and unacceptable deterioration during transport and storage.
1521
1522 (d) In blinded trials, the sponsor should implement:
1523
1524 (i) a process to blind the sponsor staff, trial participant and/or investigator
1525 as appropriate to the investigational product identity and assignment to
1526 prevent and detect inappropriate unblinding;
1527
1528 (ii) a procedure and mechanism that permits the investigator to rapidly
1529 identify the product(s) in case of a medical emergency where
1530 unblinding is considered necessary, while protecting the identity of the
1531 treatment assignment of the other trial participants;
1532
1533 (iii) a mechanism that protects the blinding of the trial where a participant’s
1534 treatment assignment is unblinded for the purpose of safety reporting
1535 to regulatory authorities and/or IRB/IEC, where appropriate.
1536
1537 (e) If significant formulation changes are made in the investigational product(s)
1538 (including active control(s) and placebo, if applicable) during the course of
1539 clinical development, the results of any additional studies of the formulated
1540 product(s) (e.g., stability, dissolution rate, bioavailability) needed to assess
1541 whether these changes would significantly alter the pharmacokinetic profile
1542 of the product should be available prior to the use of the new formulation in
1543 clinical trials.
1544 3.15.3 Supplying and Handling Investigational Product(s)
1545 (a) The sponsor is responsible for supplying the investigator(s)/institution(s) with
1546 the investigational product(s) or, where appropriate, supplying trial
1547 participants in accordance with applicable regulatory requirements and after
1548 obtaining the required approval/favourable opinion from the IRB/IEC and the
1549 regulatory authority(ies) for the trial.
1550
1551 (b) The sponsor should ensure that instructions are available for the
1552 investigator/institution or trial participants on the handling and storage of
1553 investigational product(s). The procedures should consider adequate and safe
1554 receipt, handling, storage, dispensing, retrieval of unused product from
1555 participants and return of unused investigational product(s) to the sponsor (or
36
1556 alternative disposition if authorised by the sponsor and in compliance with the
1557 applicable regulatory requirement(s)).
1558
1559 (c) The sponsor should:
1560
1561 (i) ensure timely delivery of investigational product(s) to the
1562 investigator(s) or, where appropriate, to trial participants in accordance
1563 with applicable regulatory requirements to avoid any interruption to
1564 the trial as well as for the continuation of treatment for participants.
1565
1566 (ii) maintain records that document the identity, shipment, receipt, return
1567 and destruction, or alternative disposition of the investigational
1568 product(s) (see Appendix C);
1569
1570 (iii) maintain a system for retrieving investigational products and
1571 documenting this retrieval (e.g., for deficient product recall, return and
1572 destruction, or alternative disposition after trial completion, or expired
1573 product reclaim);
1574
1575 (iv) maintain a system for the disposition of unused investigational
1576 product(s) and for the documentation of this disposition;
1577
1578 (v) take steps to ensure that the investigational product(s) are stable over
1579 the period of use and only used within the current shelf-life;
1580
1581 (vi) maintain sufficient quantities of the investigational product(s) used in
1582 the trials to reconfirm specifications should this become necessary and
1583 maintain records of batch sample analyses and characteristics. The
1584 samples should be retained either until the analyses of the trial data are
1585 complete or as required by the applicable regulatory requirement(s),
1586 whichever represents the longer retention period. The samples do not
1587 need to be kept by the sponsor in trials where an authorised medicinal
1588 product is used as an investigational product unmodified from its
1589 authorised state, since samples are kept by the manufacturer.
1590 3.16 Data and Records
1591 3.16.1 Data Handling
1592 (a) The sponsor should ensure the integrity and confidentiality of data generated
1593 and managed.
1594
1595 (b) The sponsor should apply quality control to the relevant stages of data
1596 handling to ensure that the data are of sufficient quality to generate reliable
1597 results. The sponsor should focus their quality assurance and quality control
1598 activities and data review on critical data, including its relevant metadata.
1599
37
1600 (c) The sponsor should pre-specify data to be collected and the method of its
1601 collection in the protocol (see Appendix B. Clinical Trial Protocol and
1602 Protocol Amendment(s)). Where necessary, additional details, including a
1603 data flow diagram, should be contained in a protocol-related document (e.g.,
1604 a data management plan).
1605
1606 (d) The sponsor should ensure that data acquisition tools are fit for purpose and
1607 designed to capture the information required by the protocol. They should be
1608 validated and ready for use prior to their required use in the trial.
1609
1610 (e) The sponsor should ensure that documented processes are implemented to
1611 ensure the data integrity for the full data life cycle.
1612
1613 (f) The sponsor should implement measures to ensure the safeguarding of the
1614 blinding, if any (e.g., maintain the blinding during data entry and processing).
1615
1616 (g) The sponsor should provide guidance to investigators/institutions, service
1617 providers and trial participants, where relevant, on the expectations for data
1618 capture, data changes, data retention and data disposal.
1619
1620 (h) The sponsor should not make changes to data entered by the investigator or
1621 trial participants unless justified and documented by the sponsor and agreed
1622 upon by the investigator.
1623
1624 (i) The sponsor should allow correction of errors to data, including data entered
1625 by participants, where requested by the investigators/participants. Such data
1626 corrections should be justified and supported by source records around the
1627 time of original entry.
1628
1629 (j) The sponsor should ensure that the investigator has access to data collected in
1630 accordance with the protocol during the course of the trial including relevant
1631 data from external sources, for example, central laboratory data, centrally read
1632 imaging data and, if appropriate, ePRO data that are necessary to enable the
1633 investigators to make decisions (e.g., on eligibility, treatment, continuing
1634 participation in the trial and care for the safety of the individual trial
1635 participants). The sponsor should pay special attention to data that may
1636 unblind the investigator and include the appropriate provisions in the protocol.
1637
1638 (k) The sponsor should not have exclusive control of data captured in data
1639 acquisition tools.
1640
1641 (l) The sponsor should ensure that the investigator has access to the required data
1642 for retention purposes.
1643
38
1644 (m) The sponsor should ensure that the investigator receives instructions on how
1645 to navigate systems, data and relevant metadata for the trial participants under
1646 their responsibility.
1647
1648 (n) The sponsor should seek investigator endorsement of their data at
1649 predetermined milestones.
1650
1651 (o) The sponsor should document the data management steps to be undertaken
1652 prior to data analysis. These steps may vary depending on the purpose of the
1653 analysis to be conducted (e.g., data for IDMC, for interim analysis or the final
1654 analysis).
1655
1656 (p) Prior to provision of the data for analysis, edit access to the data acquisition
1657 tools should be restricted as appropriate to the purpose of the analysis; for
1658 example, for interim analysis, the restriction may only be temporary or
1659 managed differently compared to the final analysis.
1660
1661 (q) Deviations from the planned statistical analysis or changes made to the data
1662 analysis set after the trial has been unblinded (where applicable) should be
1663 clearly documented and justified and should only occur in exceptional
1664 circumstances (e.g., data discrepancies that must be resolved for the reliability
1665 of the trial results). Data changes should be authorised by the investigator and
1666 reflected in an audit trail. Post-unblinding data changes and deviations from
1667 the planned statistical analyses should be reported in the clinical trial report.
1668
1669 (r) The sponsor should use an unambiguous trial participant identification code
1670 (see glossary term) that allows identification of all the data reported for each
1671 participant.
1672
1673 (s) The sponsor should implement appropriate measures to protect the privacy and
1674 confidentiality of personal information of trial participants, in accordance with
1675 applicable regulatory requirements on personal data protection.
1676
1677 (t) In accordance with applicable regulatory requirements, the sponsor should
1678 document what happens to data when a participant withdraws or discontinues
1679 from the trial.
1680
1681 (u) The sponsor should ensure that trial data are protected from unauthorised
1682 access, disclosure, dissemination or alteration and from inappropriate
1683 destruction or accidental loss.
1684
1685 (v) The sponsor should have processes and procedures in place for reporting
1686 incidents (including security breaches) that have a significant impact on the
1687 trial data to relevant parties, including regulatory authorities, where relevant.
1688
1689
39
1690 (w) When using computerised systems in a clinical trial, the sponsor should:
1691
1692 (i) have a record of the computerised systems used in a clinical trial. This
1693 should include the use, functionality, interfaces and validation status
1694 of each computerised system, and who is responsible for its
1695 management should be described. The record should also include a
1696 description of implemented access controls and internal and external
1697 security measures;
1698
1699 (ii) ensure that the requirements for computerised systems deployed by the
1700 sponsor (e.g., requirements for validation, audit trails, user
1701 management, backup, disaster recovery and IT security) are addressed
1702 and implemented and that documented procedures and adequate
1703 training are in place to ensure the correct development, maintenance
1704 and use of computerised systems in clinical trials (see section 4). These
1705 requirements should be proportionate to the importance of the
1706 computerised system and the data or activities they are expected to
1707 process;
1708
1709 (iii) maintain a record of the individual users who are authorised to access
1710 the system, their roles and their access privileges:
1711
1712 (iv) ensure that access rights granted to investigator site staff are in
1713 accordance with delegations by the investigator and visible to the
1714 investigator;
1715
1716 (v) for systems deployed by the investigator/institution, assess whether
1717 such systems, if identified as containing source records in the trial,
1718 (e.g., electronic health records and other record keeping systems for
1719 source data collection and investigator site files) are fit for purpose or
1720 whether the known issue(s) can be appropriately mitigated. This
1721 assessment should occur during the process of selecting clinical trial
1722 sites and should be documented;
1723
1724 (vi) ensure that there is a process in place for service providers and
1725 investigators to inform the sponsor of system defects identified or
1726 incidents that could potentially constitute a serious non-compliance
1727 with the clinical trial protocol, trial procedures or GCP in accordance
1728 with section 3.13.
40
1729 3.16.2 Statistical Programming and Data Analysis

1730 This section concerning documentation of operational aspects of clinical trial
1731 statistical activities should be read in conjunction with ICH E9 Statistical Principles
1732 for Clinical Trials, which provides detailed guidance on statistical principles for
1733 clinical development, trial design, conduct, analysis and reporting.
1734 (a) The sponsor should ensure that appropriate and documented quality control of
1735 statistical programming and data analysis is implemented (e.g., for sample size
1736 calculations, results for IDMC, outputs for clinical trial report, statistical or
1737 centralised monitoring).
1738
1739 (b) The sponsor should ensure the traceability of data transformations and
1740 derivations during data processing and analysis.
1741
1742 (c) The sponsor should ensure that the allocation to or exclusion of each trial
1743 participant from any analysis set is predefined (e.g., in the protocol or the
1744 statistical analysis plan). The rationale for inclusion or exclusion for any
1745 participant (or particular data point) should be clearly described and
1746 documented.
1747
1748 (d) Procedures should be in place to describe unblinding; these descriptions
1749 should include:
1750
1751 (i) who was unblinded, at what timepoint and for what purpose they were
1752 unblinded;
1753
1754 (ii) who should remain blinded;
1755
1756 (iii) the safeguards in place to preserve the blinding.
1757
1758 (e) The sponsor should retain the statistical programming records that relate to the
1759 output contained or used in reports of the trial results, including quality
1760 control/validation activities performed. Outputs should be traceable to the
1761 statistical software programs, and they should be dated and time stamped and
1762 protected against any changes.
1763 3.16.3 Record Keeping and Retention
1764 (a) The sponsor (or subsequent owners of the data) should retain all of the
1765 sponsor-specific essential records pertaining to the trial in conformance with
1766 the applicable regulatory requirement(s).
1767
1768 (b) The sponsor should inform the investigator(s)/institution(s) and service
1769 providers, when appropriate, in writing of the need for essential records
1770 retention and should notify the investigator(s)/institution(s) and service
1771 providers, when appropriate, in writing when the trial-related records are no
1772 longer needed.
41
1773 (c) The sponsor should report any transfer of ownership of the essential records
1774 to the appropriate authority(ies) as required by the applicable regulatory
1776 3.16.4 Record Access
1777 (a) The sponsor should ensure that it is specified in the protocol or other
1778 documented agreement that the investigator(s)/institution(s) provide direct
1779 access to source records for trial-related monitoring, audits, IRB/IEC review
1780 and regulatory inspection.
1781
1782 (b) The sponsor should ensure that trial participants have consented to direct
1783 access to their original medical records and other participant-related trial
1784 documents for trial-related monitoring, audit, IRB/IEC review and regulatory
1785 inspection as part of the informed consent.
1786 3.17 Reports
1787 3.17.1 Premature Termination or Suspension of a Trial
1788 If a trial is prematurely terminated or suspended, the sponsor should promptly inform
1789 the investigators/institutions and the regulatory authority(ies) of the termination or
1790 suspension and the reason(s) for the termination or suspension. The IRB/IEC should
1791 also be informed promptly and provided with the reason(s) for the termination or
1792 suspension by the sponsor or by the investigator/institution, in accordance with
1794 3.17.2 Clinical Trial/Study Reports
1795 (a) Whether the trial is completed or prematurely terminated or an interim analysis
1796 is undertaken for regulatory submission, the sponsor should ensure that the
1797 clinical trial reports, including interim reports, are prepared and provided to
1798 the regulatory agency(ies) as required by the applicable regulatory
1799 requirement(s). The sponsor should also ensure that the clinical trial reports in
1800 marketing applications meet the standards of ICH E3 or are otherwise in
1801 accordance with applicable regulatory requirements. (Note: ICH E3 specifies
1802 that abbreviated study reports may be acceptable in certain cases.)
1803
1804 (b) Investigators should be provided with a summary of the trial results.
1805
1806 (c) Consideration should be given to providing the investigator with information
1807 about the final treatment taken by their participants for blinded trials and a
1808 brief summary of the overall outcome of the trial. Where this information is
1809 provided to participants, the language should be non-technical, understandable
1810 to a layperson and non-promotional. The sponsor should only supply this
1811 information after the trial has been unblinded and all relevant
1812 analyses/conclusions have been completed and finalised.
42
1813 4. DATA GOVERNANCE – INVESTIGATOR AND SPONSOR

1814 This section provides guidance to investigators and sponsors (i.e., the responsible parties) on
1815 appropriate management of data integrity, traceability and security, thereby allowing the
1816 accurate reporting, verification and interpretation of the clinical trial-related information. This
1817 section should be read in conjunction with corresponding responsibilities for the investigator
1818 and the sponsor as defined in sections 2 and 3, along with ICH E8(R1) and ICH E9.
1819 The quality and amount of the information generated in a clinical trial should be sufficient to
1820 address trial objectives, provide confidence in the trial’s results and support good decision
1821 making.
1822 The systems and processes that help ensure this quality should be designed and implemented
1823 in a way that is proportionate to the risks to participants and the reliability of trial results.
1824 The following key processes should address the full data life cycle with a focus on the criticality
1825 of the data and should be implemented proportionately and documented appropriately:
1826 (a) processes to ensure data protection of trial participants’ confidential data;
1827
1828 (b) processes for managing computerised systems to ensure that they are fit for
1829 purpose and used appropriately;
1830
1831 (c) processes to safeguard essential elements of the clinical trial, such as
1832 randomisation, dose escalation and blinding;
1833
1834 (d) processes to support key decision making, such as data finalisation prior to
1835 analysis, unblinding, allocation to analysis data sets, changes in clinical trial
1836 design and, where applicable, the activities of, for example, an IDMC.
1837 4.1 Safeguard Blinding in Data Governance
1838 4.1.1 Maintaining the integrity of the blinding is important in particular in the design of
1839 systems, management of users’ account, delegation of responsibilities with respect to
1840 data handling and provision of data access at sites, data transfers, database review
1841 prior to planned unblinding and statistical analysis across all appropriate stages of the
1842 trial.
1843
1844 4.1.2 Roles, responsibilities and procedures for access to unblinded information should be
1845 defined and documented by all relevant parties according to the protocol; this
1846 information may also be included in the data management plans and statistical
1847 analysis plans. For example, in blinded trials, sponsor staff or designated third parties
1848 who are involved in operation of the trial and directly or indirectly interact with site
1849 investigator staff should not have access to unblinding information.
1850
1851 4.1.3 The potential for unblinding should be part of the risk assessment of a blinded trial.
1852 Any planned or unplanned unblinding, including accidental or emergency unblinding,
1853 should be documented and assessed for impact to trial results.
43
1854 4.2 Data Life Cycle Elements

1855 Procedures should be in place to cover the full data life cycle.
1856 4.2.1 Data Capture
1857 (a) The requirements for and extent of data verification, when data captured on
1858 paper or in an electronic health record are manually transcribed into a
1859 computerised system, should take the criticality of the data into account. Refer
1860 to section 4.2.3 for data entered directly in data acquisition tools.
1861 (b) Acquired data from any source should be accompanied by relevant metadata.
1862 At the point of data capture, automated data validation checks should be
1863 considered as required based upon risk, and their implementation should be
1864 controlled and documented.
1865
1866 4.2.2 Relevant Metadata, Including Audit Trails
1867 The approach used by the responsible party for implementing, evaluating, accessing,
1868 managing and reviewing relevant metadata associated with critical data should entail:
1869
1870 (a) Evaluating the system for the types and content of metadata available to ensure
1871 that:
1872 (i) computerised systems maintain logs of user account creation, changes
1873 to user roles and permissions and user access;
1874
1875 (ii) systems are designed to permit data changes in such a way that the
1876 initial data entry and any subsequent changes or deletions are
1877 documented, including, where appropriate, using a risk-based
1878 evaluation, the reason for the change if it is not implicit;
1879
1880 (iii) systems record and maintain workflow actions in addition to direct
1881 data entry/changes into the system.
1882 (b) Ensuring that audit trails, reports and logs are not disabled or modified except
1883 in rare circumstances and only if a log of such action and justification is
1884 maintained;
1885
1886 (c) Ensuring that audit trails and logs are decipherable and can facilitate analysis;
1887
1888 (d) Ensuring that the automatic capture of date and time of data entries or transfer
1889 using data acquisition tools are unambiguous (e.g., coordinated universal time
1890 (UTC));
1891
1892 (e) Determining which of the identified metadata require review and retention.
44
1893 4.2.3 Review of Data and Metadata

1894 Procedures for review of trial-specific data, audit trails and other relevant metadata
1895 should be in place. It should be a planned activity, and the extent and nature should
1896 be adapted to the individual trial and adjusted based on experience during the trial.
1897 4.2.4 Data Corrections
1898 There should be processes to correct data errors that could impact the reliability of the
1899 trial results. Corrections should be attributed to the entity making the correction,
1900 justified and supported by source records around the time of original entry, and
1901 performed in a timely manner.
1902 4.2.5 Data Transfer, Exchange and Migration
1903 Validated processes or other appropriate processes such as reconciliation should be in
1904 place to ensure that electronic data transferred between computerised systems retains
1905 its integrity and preserves its confidentiality. The transfer process should be
1906 documented to ensure traceability, and data reconciliation should be implemented as
1907 appropriate.
1908 4.2.6 Finalisation of Data Sets Prior to Analysis
1909 (a) Data of sufficient quality for interim and final analysis are achieved by
1910 implementing timely and reliable processes for data capture, verification,
1911 validation, review and rectification of errors and omissions that have a
1912 meaningful impact on the safety of trial participants and/or the reliability of
1913 the trial results.
1914
1915 (b) Activities undertaken to finalise the data sets prior to analysis should be
1916 confirmed and documented in accordance with pre-specified procedures.
1917 These activities may include reconciliation of entered data and data sets or
1918 reconciliation of relevant databases, correction of data errors and omissions,
1919 medical coding, compilation and addressing the impact of non-compliance
1920 including protocol deviations.
1921
1922 (c) Data extraction and determination of data analysis sets should take place in
1923 accordance with the planned statistical analysis and should be documented.
1924 4.3 Computerised Systems
1925 As described in sections 2 and 3, the responsibilities of the sponsor, investigator and
1926 the activities of other parties with respect to a computerised system used in clinical
1927 trials should be clear and documented. In summary, the sponsor is responsible for
1928 ensuring that for computerised systems which they put in place, the expectations for
1929 computerised systems as described in this section are addressed in a risk proportionate
1930 manner. The sponsor should review whether the systems used by the
1931 investigator/institution (e.g., electronic health records and other record keeping
1932 systems for source data collection) are fit for purpose in the context of the trial. In the
1933 event that the investigator/institution deploys systems specifically for the purposes of
45
1934 conducting clinical trials, the investigator/institution should ensure that the
1935 expectations are proportionately addressed and implemented.
1936 The responsible party should ensure that those developing computerised systems for
1937 clinical trials are aware of the intended purpose and the regulatory requirements that
1938 apply to them.
1939 It is recommended that representatives of intended participant populations and
1940 healthcare professionals are involved in the design of the system, where relevant, to
1941 ensure that computerised systems are suitable for use by the intended user population.
1942 4.3.1 Procedures for the Use of Computerised Systems
1943 Documented procedures should be in place to ensure the appropriate use of
1944 computerised systems in clinical trials for essential activities related to data collection,
1945 handling and management.
1946 4.3.2 Training
1947 The responsible party should ensure that those using computerised systems are
1948 appropriately trained in their use.
1949 4.4 Security of Computerised Systems
1950 4.4.1 The security of the trial data and records should be managed throughout the data life
1951 cycle.
1952
1953 4.4.2 The responsible party should ensure that security controls are maintained for
1954 computerised systems. These controls should include user management and ongoing
1955 measures to prevent, detect and/or mitigate security breaches. Aspects such as user
1956 authentication requirements and password management, firewall settings, antivirus
1957 software, security patching, system monitoring and penetration testing should be
1958 considered.
1959
1960 4.4.3 The responsible party should maintain adequate backup of the data.
1961
1962 4.4.4 Procedures should cover the following: system security measures, data backup and
1963 disaster recovery.
1964 4.5 Validation of Computerised Systems
1965 4.5.1 The responsible party is responsible for the validation status of the system throughout
1966 its life cycle. The approach to validation of computerised systems should be based on
1967 a risk assessment that considers the intended use of the system; the purpose and
1968 importance of the data/record that is collected/generated, maintained and retained in
1969 the system; and the potential of the system to affect the well-being, rights and safety
1970 of trial participants and the reliability of trial results.
1971
1972 4.5.2 Validation should demonstrate that the system conforms to the established
1973 requirements for completeness, accuracy, and reliability and is consistent with
1974 intended performance.
46
1975 4.5.3 Systems should be appropriately validated prior to use with adequate change control
1976 procedures implemented.
1977
1978 4.5.4 Validation of changes should be based on risk and consider both previously collected
1979 and new data.
1980
1981 4.5.5 Both basic system functionality and protocol specific configurations and
1982 customisations, including automated data entry checks and calculations, should be
1983 validated. Interfaces between systems should also be defined and validated. Different
1984 degrees of qualification/validation may be needed for bespoke systems, systems
1985 designed to be configured or systems where no alterations are needed.
1986
1987 4.5.6 Where relevant, procedures should cover the following: system design, validation,
1988 and functionality testing; release; setup; installation and change control until
1989 decommissioning.
1990
1991 4.5.7 The responsible party should ensure that the computerised systems used in clinical
1992 trial processes are qualified and validated, including those developed by other parties.
1993 They should ensure that qualification and validation documentation is maintained and
1994 retained.
1995
1996 4.5.8 Validation should generally include defining the requirements and specifications for
1997 the system and their testing, along with the associated documentation, to ensure the
1998 system is fit for purpose, especially for critical functionality, such as randomisation,
1999 dosing and dose titrations and reductions, and collection of endpoint data.
2000
2001 4.5.9 Unresolved issues, if any, should be justified and, where relevant, addressed by
2002 mitigations prior to and/or during the continued use of the system.
2003
2004 4.5.10 The trial-specific systems (including updates resulting from protocol amendments)
2005 should only be implemented to enable the conduct of the trial by the investigator after
2006 all necessary approvals for the clinical trial have been received.
2007 4.6 System Failure
2008 Contingency procedures should be in place to prevent loss or lack of accessibility to data
2009 essential to participant safety, trial decisions or trial outcomes.
2010 4.7 Technical Support
2011 4.7.1 Where appropriate, there should be mechanisms (e.g., help desk support) in place to
2012 document, evaluate and manage issues with the computerised systems (e.g., raised by
2013 users), and there should be periodic review of these cumulative issues to identify those
2014 that are repeated and/or systemic.
2015
2016 4.7.2 Defects and issues should be resolved according to their criticality. Issues with high
2017 criticality should be resolved in a timely manner.
47
2018 4.8 User Management

2019 4.8.1 Access controls are integral to computerised systems used in clinical trials to limit
2020 system access to authorised users and to ensure attributability to an individual. The
2021 security measures should be selected in such a way that they achieve the intended
2022 security and do not unduly impact user-friendliness.
2023 4.8.2 Procedures should be in place to ensure that user access rights are appropriately
2024 assigned based on a user’s duties and functions, blinding arrangements and the
2025 organisation to which users belong. Access rights should be revoked when they are
2026 no longer needed.
2027 4.8.3 Authorised users and access privileges should be clearly documented, maintained and
2028 retained. These records should include any updates to a user’s roles, access rights and
2029 permissions, and time of access privileges given (e.g., time stamp).
48
2030 GLOSSARY
2031 Adverse Events and Adverse Reaction-related definitions:
2032 Adverse Event (AE): Any unfavourable medical occurrence in a trial participant. The
2033 adverse event does not necessarily have a causal relationship with the treatment.
2034 Adverse Drug Reaction (ADR):
2035 • in the pre-approval clinical experience with a new investigational product or its new
2036 usages (particularly as the therapeutic dose(s) may not be established):
2037 unfavourable and unintended responses, such as a sign (e.g., laboratory results),
2038 symptoms or disease related to any dose of a medicinal product where a causal
2039 relationship between a medicinal product and an adverse event is a reasonable
2040 possibility. The level of certainty about the relatedness of the adverse drug reaction
2041 to an investigational product will vary. If the ADR is suspected to be medicinal
2042 product-related with a high level of certainty, it should be included in the reference
2043 safety information (RSI) and/or the Investigator’s Brochure (IB).
2044
2045 • for marketed medicinal products: a response to a drug that is noxious and
2046 unintended and that occurs at doses normally used in humans for prophylaxis,
2047 diagnosis or therapy of diseases or for modification of physiological function.
2048 (See ICH E2A Clinical Safety Data Management: Definitions and Standards for
2049 Expedited Reporting).
2050 Serious Adverse Event (SAE): Any unfavourable medical occurrence that is considered
2051 serious at any dose if it:
2052 • results in death
2053 • is life-threatening
2054 • requires inpatient hospitalisation or prolongation of existing hospitalisation
2055 • results in persistent or significant disability/incapacity
2056 • is a congenital anomaly/birth defect (see ICH E2A)
2057 Suspected Unexpected Serious Adverse Reaction (SUSAR): an adverse reaction that
2058 meets three criteria: suspected, unexpected and serious.
2059 • Suspected: There is a reasonable possibility that the drug caused the adverse drug
2060 reaction.
2061
2062 • Unexpected: An adverse reaction, the nature or severity of which is not consistent
2063 with the applicable product information (e.g., the RSI, see glossary term contained
2064 within the Investigator’s Brochure or alternative documents according to applicable
2065 regulatory requirements. Refer to ICH E2F Development Safety Update Report for
2066 more information about RSI.
2067
2068 • Serious: See above for SAE.
2069
49
2070 Agreement
2071 A document or set of documents describing the details of any arrangements on delegation or
2072 transfer, distribution and/or sharing of activities and, if appropriate, on financial matters
2073 between two or more parties. This could be in the form of a contract. The protocol may serve
2074 as the basis of an agreement.
2075 Applicable Regulatory Requirement(s)
2076 Any law(s) and regulation(s) addressing the conduct of clinical trials of investigational
2077 products.
2078 Assent
2079 Affirmative agreement of a minor to participate in clinical trial. The absence of expression of
2080 agreement or disagreement should not be interpreted as assent.
2081 Audit
2082 A systematic and independent examination of trial-related activities and records performed by
2083 the sponsor, service provider (including contract research organisation (CRO)) or institution to
2084 determine whether the evaluated trial-related activities were conducted and the data were
2085 recorded, analysed and accurately reported according to the protocol, applicable standard
2086 operating procedures (SOPs), Good Clinical Practice (GCP) and the applicable regulatory
2088 Audit Certificate
2089 A declaration of confirmation by the auditor that an audit has taken place.
2090 Audit Report
2091 A record describing the conduct and outcome of the audit.
2092 Audit Trail
2093 Metadata records that allow reconstruction of the course of events by capturing details on
2094 actions (manual or automated) performed relating to information and data collection and, where
2095 applicable, to activities in computerised systems. The audit trail should show activities, initial
2096 entry, and changes to data fields or records, by whom, when and, where applicable, why. In
2097 computerised systems, the audit trail should be secure, computer generated and timestamped.
2098 Blinding/Masking
2099 A procedure in which one or more parties to the trial are kept unaware of the treatment
2100 assignment(s). Single-blinding usually refers to the participant(s) being unaware, and double-
2101 blinding usually refers to the participant(s), investigator(s) or other trial staff, as appropriate,
2102 being unaware of the treatment assignment(s).
2103 Case Report Form (CRF)
2104 A tool designed to record protocol-required information to be reported by the investigator to
2105 the sponsor on each trial participant (see Data Acquisition Tool).
2106
50
2107 Certified Copy

2108 A copy (irrespective of the type of media used) of the original record that has been verified
2109 (i.e., by a dated signature or by generation through a validated process) to have the same
2110 information as the original, including relevant metadata, where applicable.
2111 Clinical Trial
2112 Any interventional investigation in human participants intended to discover or verify the
2113 clinical, pharmacological and/or other pharmacodynamic effects of an investigational
2114 product(s); and/or to identify any adverse reactions to an investigational product(s); and/or to
2115 study absorption, distribution, metabolism and excretion of an investigational product(s) with
2116 the object of ascertaining its safety and/or efficacy.
2117 Clinical Trial/Study Report (CSR)
2118 A documented description of a trial of any investigational product conducted in human
2119 participants, in which the clinical and statistical description, presentations and analyses are
2120 fully integrated into a single report (see ICH E3 Structure and Content of Clinical Study
2121 Reports).
2122 Comparator
2123 An investigational or authorised medicinal product (i.e., active control), placebo or standard of
2124 care used as a reference in a clinical trial.
2125 Compliance (in relation to trials)
2126 Adherence to the trial-related requirements, GCP requirements and the applicable regulatory
2127 requirements.
2128 Confidentiality
2129 Prevention of disclosure to other than authorised individuals of a sponsor’s proprietary
2130 information or of a participant’s identity or their confidential information.
2131 Coordinating Investigator
2132 An investigator assigned the responsibility for the coordination of investigators at different
2133 investigator sites participating in a multicentre trial (if appropriate).
2134 Computerised Systems Validation
2135 A process of establishing and documenting that the specified requirements of a computerised
2136 system can be consistently fulfilled from design until decommissioning of the system or
2137 transition to a new system. The approach to validation should be based on a risk assessment
2138 that takes into consideration the intended use of the system and the potential of the system to
2139 affect trial participant protection and the reliability of trial results.
2140 Contract Research Organisation (CRO)
2141 See Service Provider.
2142
51
2143 Data Acquisition Tool (DAT)

2144 A paper or electronic tool designed to collect data and associated metadata from a data
2145 originator in a clinical trial according to the protocol and to report the data to the sponsor.
2146 The data originator may be a human (e.g., the participant or trial staff), a machine (e.g.,
2147 wearables and sensors) or an electronic transfer of data from one system to another (e.g.,
2148 extraction of data from an electronic health record or laboratory system).
2149 Examples of DATs include but are not limited to CRFs, interactive response technologies
2150 (IRTs), patient-reported outcomes (PROs), clinical outcome assessments (COAs) and wearable
2151 devices, irrespective of the media used.
2152 Direct Access
2153 Permission to examine, analyse and verify records that are important to the evaluation of a
2154 clinical trial and may be performed in person or remotely. Any party (e.g., domestic and foreign
2155 regulatory authorities, sponsor’s monitors and auditors) with direct access should take
2156 reasonable precautions within the constraints of the applicable regulatory requirement(s) to
2157 maintain the confidentiality of participants’ identities and their data and sponsor’s proprietary
2158 information.
2159 Essential Records
2160 Essential records are the documents and data (and relevant metadata), in any format, associated
2161 with a clinical trial that facilitate the ongoing management of the trial and collectively allow
2162 the evaluation of the methods used, the factors affecting a trial and the actions taken during the
2163 trial conduct to determine the reliability of the trial results produced and the verification that
2164 the trial was conducted in accordance with GCP and applicable regulatory requirements (see
2165 Appendix C. Essential Records for the Conduct of a Clinical Trial).
2166 Good Clinical Practice (GCP)
2167 A standard for the planning, initiating, performing, recording, oversight, evaluation, analysis
2168 and reporting of clinical trials that provides assurance that the data and reported results are
2169 reliable and that the rights, safety and well-being of trial participants are protected.
2170 Impartial Witness
2171 A person who is independent of the trial who cannot be unfairly influenced by people involved
2172 with the trial, who attends the informed consent process if the participant or the participant’s
2173 legally acceptable representative cannot read, and who reads the informed consent form and
2174 any other documented information supplied or read to the participant and/or their legally
2175 acceptable representative.
2176 Independent Data Monitoring Committee (IDMC)
2177 An independent data monitoring committee (e.g., data safety monitoring board) that may be
2178 established by the sponsor to assess at intervals the progress of a clinical trial, the safety data
2179 and the critical efficacy endpoints, and to recommend to the sponsor whether to continue,
2180 modify or stop a trial.
2181
52
2182 Informed Consent

2183 A process by which a participant or their legally accepted representative voluntarily confirms
2184 their willingness to participate in a trial after having been informed and been provided with the
2185 opportunity to discuss all aspects of the trial that are relevant to the participant’s decision to
2186 participate. Varied approaches to the provision of information and the discussion about the trial
2187 can be used. This can include, for example, providing text in different formats, images and
2188 videos and using telephone or video conferencing with investigator site staff. Informed consent
2189 is documented by means of a written or electronic, signed and dated informed consent form.
2190 Obtaining consent remotely may be considered when appropriate.
2191 Inspection
2192 The act by a regulatory authority(ies) of conducting an official review of documents, facilities,
2193 records and any other resources that are deemed by the authority(ies) to be related to the clinical
2194 trial and that may be accessed at the investigator site, at the sponsor’s and/or service provider’s
2195 (including CRO’s) facilities, or at other establishments deemed appropriate by the regulatory
2196 authority(ies). Some aspects of the inspection may be conducted remotely.
2197 Institution
2198 Any public or private entity or agency or medical or dental organisation in whose remit clinical
2199 trials are conducted.
2200 Institutional Review Board (IRB)/Independent Ethics Committee (IEC)
2201 An independent body (a review board or a committee, institutional, regional, national or
2202 supranational) constituted of medical professionals and non-medical members whose
2203 responsibility it is to ensure the protection of the rights, safety and well-being of human
2204 participants involved in a trial and to provide public assurance of that protection by, among
2205 other things, reviewing and approving/providing favourable opinion on the trial protocol, the
2206 suitability of the investigator(s), the facilities, and the methods and material to be used in
2207 obtaining and documenting informed consent of the trial participants. The legal status,
2208 composition, function, operations and regulatory requirements pertaining to IRBs/IECs may
2209 differ among countries but should allow the IRB/IEC to act in agreement with GCP as
2210 described in this guideline.
2211 Interim Clinical Trial/Study Report
2212 A report of intermediate results and their evaluation based on analyses performed during the
2213 course of a trial.
2214 Investigational Product
2215 A pharmaceutical form of an active ingredient or placebo being tested or used as a reference in
2216 a clinical trial, including a product with a marketing authorisation when used or assembled
2217 (formulated or packaged) in a way different from the approved form, or when used for an
2218 unapproved indication, or when used to gain further information about an approved use.
2219
2220
53
2221 Investigator
2222 A person responsible for the conduct of the clinical trial, including the trial participants for
2223 whom that person has responsibility during the conduct of the trial. If a trial is conducted by a
2224 team of individuals, the investigator is the responsible leader of the team and may be called the
2225 principal investigator. Where an investigator/institution is referenced in this guideline, it
2226 describes expectations that may be applicable to the investigator and/or the institution in some
2227 regions. Where required by the applicable regulatory requirements, the “investigator” should
2228 be read as “investigator and/or the institution.”
2229 Investigator’s Brochure (IB)
2230 A compilation of the clinical and nonclinical data on the investigational product(s) that is
2231 relevant to the study of the investigational product(s) in human participants (see Appendix A.
2232 Investigator’s Brochure).
2233 Investigator Site
2234 The location(s) at or from where trial-related activities are conducted under the
2235 investigator’s/institution’s supervision.
2236 Legally Acceptable Representative
2237 An individual or juridical or other body authorised under applicable law to consent, on behalf
2238 of a prospective participant, to the participant’s participation in the clinical trial.
2239 Metadata
2240 The contextual information required to understand a given data element. Metadata is structured
2241 information that describes, explains or otherwise makes it easier to retrieve, use or manage
2242 data. For the purpose of this guideline, relevant metadata are those needed to reconstruct the
2243 trial conduct.
2244 Monitoring
2245 The act of overseeing the progress of a clinical trial and of ensuring that the clinical trial is
2246 conducted, recorded and reported in accordance with the protocol, SOPs, GCP and the
2248 Monitoring Plan
2249 A document that describes the strategy, methods, responsibilities and requirements for
2250 monitoring the trial.
2251 Monitoring Report
2252 A documented report following site and/or centralised monitoring activities.
2253 Multicentre Trial
2254 A clinical trial conducted according to a single protocol but at more than one investigator site.
2255 Nonclinical Study
2256 Biomedical studies not performed on human participants.
54
2257 Original Medical Record

2258 See Source Records.
2259 Protocol
2260 A document that describes the objective(s), design, methodology, statistical considerations and
2261 organisation of a trial. The protocol usually also gives the background and rationale for the
2262 trial, but these could be provided in other protocol referenced documents. Throughout the ICH
2263 GCP Guideline, the term protocol refers to protocol and protocol amendments.
2264 Protocol Amendment
2265 A documented description of a change(s) to a protocol.
2266 Quality Assurance (QA)
2267 All those planned and systematic actions that are established to ensure that the trial is performed
2268 and the data are generated, documented (recorded) and reported in compliance with GCP and
2269 the applicable regulatory requirement(s).
2270 Quality Control (QC)
2271 The operational techniques and activities undertaken to verify that the requirements for quality
2272 of the trial-related activities have been fulfilled.
2273 Randomisation
2274 The process of deliberately including an element of chance when assigning participants to
2275 groups that receive different treatments in order to reduce bias.
2276 Reference Safety Information (RSI)
2277 Contains a cumulative list of ADRs that are expected for the investigational product being
2278 administered to participants in a clinical trial. The RSI is included in the Investigator’s
2279 Brochure.
2280 Regulatory Authorities
2281 Bodies having the power to regulate, including those that review submitted protocols and
2282 clinical data and those that conduct inspections. These bodies are sometimes referred to as
2283 competent authorities.
2284 Service Provider
2285 A person or organisation (commercial, academic or other) providing a service used during the
2286 conduct of a clinical trial to either the sponsor or the investigator to fulfil one or more of their
2287 trial-related activities.
2288 Signature
2289 A unique mark, symbol or entry in line with applicable regulatory requirements and/or practice
2290 to show expression of will and allow authentication of the signatory.
2291
55
2292 Source Records

2293 Original documents or data (which includes relevant metadata) or certified copies of the
2294 original documents or data, irrespective of the media used. This may include trial participants’
2295 medical/health records/notes/charts; data provided/entered by trial participants (e.g., electronic
2296 patient-reported outcome (ePROs)); healthcare providers’ records from pharmacies,
2297 laboratories and other facilities involved in the clinical trial; and data from automated
2298 instruments, such as wearables and sensors.
2299 Sponsor
2300 An individual, company, institution, or organisation that takes responsibility for the initiation,
2301 management and arrangement of the financing of a clinical trial. A clinical trial may have one
2302 or several sponsors where permitted under regulatory requirements. All sponsors have the
2303 responsibilities of a sponsor set out in this guideline. In accordance with regulatory
2304 requirements, sponsors may decide in a documented agreement setting out their respective
2305 responsibilities. Where the agreement does not specify to which sponsor a given responsibility
2306 is attributed, that responsibility lies with all sponsors.
2307 Sponsor-Investigator
2308 An individual who both initiates and conducts, alone or with others, a clinical trial, and under
2309 whose immediate direction the investigational product is administered to, dispensed to or used
2310 by a participant. The term does not include any person other than an individual (e.g., the term
2311 does not include a corporation or an agency). The obligations of a sponsor-investigator include
2312 both those of a sponsor and those of an investigator.
2313 Standard Operating Procedures (SOPs)
2314 Detailed, documented instructions to achieve uniformity of the performance of a specific
2315 activity.
2316 Sub-investigator
2317 Any individual member of the clinical trial team designated and supervised by the investigator
2318 to perform critical trial-related procedures and/or to make important trial-related decisions
2319 (e.g., associates, residents, research fellows).
2320 Trial Participant
2321 An individual who participates in a clinical trial, either as a recipient of the investigational
2322 product(s) or as a control.
2323 Trial Participant Identification Code
2324 A unique identifier assigned to each trial participant to protect the participant’s identity and
2325 used in lieu of the participant’s name when the investigator reports adverse events and/or other
2326 trial-related data.
2327 Vulnerable Participants
2328 Individuals whose willingness to volunteer in a clinical trial may be unduly influenced by the
2329 expectation, whether justified or not, of benefits associated with participation or of a retaliatory
56
2330 response from senior members of a hierarchy in case of refusal to participate. Examples are
2331 members of a group with a hierarchical structure, such as medical, pharmacy, dental and
2332 nursing students; subordinate hospital and laboratory personnel; employees of the
2333 pharmaceutical industry; members of the armed forces and persons kept in detention. Other
2334 vulnerable participants may include persons in nursing homes, unemployed or impoverished
2335 persons, patients in emergency situations, ethnic minority groups, homeless persons, nomads,
2336 refugees, minors and those incapable of giving consent.
57
2337 APPENDICES
2338 Appendix A. INVESTIGATOR’S BROCHURE
2339 A.1 Introduction
2340 The Investigator’s Brochure (IB) is a compilation of the clinical and nonclinical data on the
2341 investigational product(s) 1 that are relevant to the study of the product(s) in human participants.
2342 Its purpose is to provide the investigators and others involved in the trial with the information
2343 to facilitate their understanding of the rationale for and their compliance with many key
2344 features of the protocol, such as the dose, dose frequency/interval, methods of administration
2345 and safety monitoring procedures.
2346
2347 A.1.1 Development of the Investigator’s Brochure
2348 Generally, the sponsor is responsible for ensuring that an up-to-date IB is developed.
2349 In the case of an investigator-initiated trial, the sponsor-investigator should determine
2350 whether a brochure is available from the product license/marketing authorisation
2351 holder. If the investigational product is provided by the sponsor-investigator, then they
2352 should provide the necessary information to the investigator site staff. Where
2353 permitted by regulatory authorities, the current scientific information such as a basic
2354 product information brochure (e.g., summary of product characteristics package
2355 leaflet, or labelling) may be an appropriate alternative, provided that it includes
2356 current, comprehensive and detailed information on all aspects of the investigational
2357 product that might be of importance to the investigator. If an authorised medicinal
2358 product is being studied for a new use (i.e., a new indication), an IB specific to that
2359 new use should be prepared unless there is a rationale for only one IB. The IB should
2360 be reviewed at least annually and revised as necessary in compliance with a sponsor’s
2361 documented procedures. More frequent revision may be appropriate depending on the
2362 stage of development and the generation of relevant new information. Relevant new
2363 information may be so important that it needs to be communicated to the investigators
2364 and possibly to the IRBs/IECs and/or regulatory authorities before it is included in a
2365 revised IB.
2366
2367 A.1.2 Reference Safety Information and Risk-Benefit Assessment
2368 The reference safety information (RSI) contained in the IB provides an important
2369 reference point for expedited reporting of suspected unexpected serious adverse
2370 reactions (SUSARs) in the clinical trial. The IB also provides insight to support the
2371 clinical management of the participants during the course of the clinical trial. The
2372 information should be presented in a concise, simple, objective, balanced and non-
2373 promotional form that enables a clinician or potential investigator to understand it and
2374 make their own unbiased risk-benefit assessment of the appropriateness of the
2375 proposed trial. For this reason, a medically qualified person should be involved in the
2376 generation of an IB, but the contents of the IB should be approved by the disciplines
2377 that generated the described data.
1
For the purpose of this guideline, the term “investigational products” should be considered synonymous with
drugs, medicines, medicinal products, vaccines and biological products.
58
2378 A.2 General Considerations

2379 These considerations delineate the minimum information that should be included in an IB. It is
2380 expected that the type and extent of information available will vary with the stage of
2381 development of the investigational product.
2382 The IB should include;
2383 A.2.1 Title Page
2384 This should provide the sponsor’s name, the identity of each investigational product
2385 (i.e., research number, chemical or approved generic name and trade name(s) where
2386 legally permissible and desired by the sponsor) and the release date. It is also
2387 suggested that an edition number and a reference to the number and date of the edition
2388 it supersedes be provided along with the cut-off date for data inclusion in the version.
2389 Where appropriate, a signature page may be included.
2390 A.2.2 Confidentiality Statement
2391 The sponsor may wish to include a statement instructing the investigator and other
2392 recipients to treat the IB as a confidential document for the sole information and use
2393 of the investigator/institution, investigator site staff, regulatory authorities and the
2394 institutional review board/independent ethics committee (IRB/IEC).
2395 A.3 Contents of the Investigator’s Brochure
2396 The IB should contain the following sections, each with literature references (publications or
2397 reports) included at the end of each chapter, where appropriate;
2398 A.3.1 Table of Contents
2399 A.3.2 Summary
2400 A brief summary (preferably not exceeding two pages) should be given, highlighting
2401 the significant physical, chemical, pharmaceutical, pharmacological, toxicological,
2402 pharmacokinetic, metabolic and clinical information available that is relevant to the
2403 stage of clinical development of the investigational product.
2404 A.3.3 Introduction
2405 A brief introductory statement should be provided that contains the chemical name
2406 (and generic and trade name(s) when approved) of the investigational product(s); all
2407 active ingredients; the pharmacological class of the investigational product(s) and its
2408 expected position within this class (e.g., advantages); the rationale for performing
2409 research with the investigational product(s); and the anticipated prophylactic,
2410 therapeutic or diagnostic indication(s). Finally, the introductory statement should
2411 provide the general approach to be followed in evaluating the investigational product.
2412 A.3.4 Physical, Chemical and Pharmaceutical Properties and Formulation
2413 A description should be provided of the investigational product substance(s)
2414 (including the chemical and/or structural formula(e)), and a brief summary should be
2415 given of the relevant physical, chemical and pharmaceutical properties.
59
2416 To permit appropriate safety measures to be taken in the course of the trial, a
2417 description of the formulation(s) to be used, including excipients, should be provided
2418 and justified if clinically relevant. Instructions for the storage and handling of the
2419 dosage form(s) should also be given.
2420 Any structural similarities to other known compounds should be mentioned.
2421 A.3.5 Nonclinical Studies
2422 Introduction
2423 The results of all relevant nonclinical pharmacology, toxicology, pharmacokinetic and
2424 investigational product metabolism studies should be provided in summary form. This
2425 summary should address the methodology used, the results and a discussion of the
2426 relevance of the findings to the investigated therapeutic and the possible unfavourable
2427 and unintended effects in humans.
2428 The information provided may include the following, as appropriate, if
2429 known/available:
2430 • species tested
2431 • number and sex of animals in each group
2432 • unit dose (e.g., milligram/kilogram (mg/kg))
2433 • dose interval
2434 • route of administration
2435 • duration of dosing
2436 • information on systemic distribution
2437 • duration of post-exposure follow-up
2438 • results, including the following aspects:
2439 - nature and frequency of pharmacological or toxic effects
2440 - severity or intensity of pharmacological or toxic effects
2441 - time to onset of effects
2442 - reversibility of effects
2443 - duration of effects
2444 - dose response
2445 Tabular format/listings should be used whenever possible to enhance the clarity of the
2446 presentation.
2447 The following sections should discuss the most important findings from the studies,
2448 including the dose response of observed effects, the relevance to humans and any
2449 aspects to be studied in humans. If applicable, the effective and nontoxic dose findings
2450 in the same animal species should be compared (i.e., the therapeutic index should be
2451 discussed). The relevance of this information to the proposed human dosing should
2452 be addressed. Whenever possible, comparisons should be made in terms of
2453 blood/tissue levels rather than on a mg/kg basis.
2454 (a) Nonclinical Pharmacology
2455 A summary of the pharmacological aspects of the investigational product and, where
2456 appropriate, its significant metabolites studied in animals should be included. Such a
60
2457 summary should incorporate studies that assess potential therapeutic activity (e.g.,
2458 efficacy models, receptor binding and specificity) as well as those that assess safety
2459 (e.g., special studies to assess pharmacological actions other than the intended
2460 therapeutic effect(s)).
2461 (b) Pharmacokinetics and Product Metabolism in Animals
2462 A summary of the pharmacokinetics and biological transformation and disposition of
2463 the investigational product in all species studied should be given. The discussion of
2464 the findings should address the absorption and the local and systemic bioavailability
2465 of the investigational product and its metabolites and their relationship to the
2466 pharmacological and toxicological findings in animal species.
2467 (c) Toxicology
2468 A summary of the toxicological effects found in relevant studies conducted in
2469 different animal species should be described under the following headings where
2470 appropriate:
2471 • single dose
2472 • repeated dose
2473 • carcinogenicity
2474 • special studies (e.g., irritancy and sensitisation)
2475 • reproductive toxicity
2476 • genotoxicity (mutagenicity)
2477 A.3.6 Effects in Humans
2478 Introduction
2479 A thorough discussion of the known effects of the investigational product(s) in
2480 humans should be provided, including information on pharmacokinetics, metabolism,
2481 pharmacodynamics, dose response, safety, efficacy and other pharmacological
2482 activities. Where possible, a summary of each completed clinical trial and ongoing
2483 trials where interim results are available that may inform the safety evaluation should
2484 be provided. Information should also be provided regarding results of any use of the
2485 investigational product(s) other than from in clinical trials, such as from experience
2486 during marketing.
2487 (a) Pharmacokinetics and Product Metabolism in Humans
2488 A summary of information on the pharmacokinetics of the investigational product(s)
2489 should be presented, including the following, if available:
2490 • pharmacokinetics (including metabolism, as appropriate, and absorption,
2491 plasma protein binding, distribution and elimination)
2492 • bioavailability of the investigational product (absolute, where possible, and/or
2493 relative) using a reference dosage form
2494 • population subgroups (e.g., sex, age and impaired organ function)
2495 • interactions (e.g., product-product interactions and effects of food)
61
2496 • other pharmacokinetic data (e.g., results of population studies performed within
2497 clinical trial(s))
2498
2499 (b) Safety and Efficacy
2500 A summary of information should be provided about the investigational
2501 product’s/products’ (including metabolites, where appropriate) safety,
2502 pharmacodynamics, efficacy and dose response that was obtained from preceding
2503 trials in humans (healthy volunteers and/or patients). The implications of this
2504 information should be discussed. In cases where a number of clinical trials have been
2505 completed, the use of summaries of safety and efficacy across multiple trials by
2506 indications in subgroups may provide a clear presentation of the data. Tabular
2507 summaries of adverse drug reactions for all the clinical trials (including those for all
2508 the studied indications) would be useful. Important differences in adverse drug
2509 reaction patterns/incidences across indications or subgroups should be discussed.
2510 The IB should provide a description of the possible risks and adverse drug reactions
2511 to be anticipated on the basis of prior experiences with the product under investigation
2512 and with related products. There should be a list of adverse reactions, clearly identified
2513 as the reference safety information section, including information on their frequency
2514 and nature. This list should be used for determining the expectedness of a suspected
2515 serious adverse reaction and subsequently whether it needs to be expedited in
2516 accordance with regulatory requirements. A description should also be provided of
2517 the precautions or special monitoring to be done as part of the investigational use of
2518 the product(s).
2519 (c) Marketing Experience
2520 The IB should identify countries where the investigational product has been marketed
2521 or approved. Any significant information arising from the marketed use should be
2522 summarised (e.g., formulations, dosages, routes of administration, adverse drug
2523 reactions). The IB should also identify all the countries where the investigational
2524 product did not receive approval/registration for marketing or was withdrawn from
2525 marketing/registration.
2526 A.3.7 Summary of Data and Guidance for the Investigator
2527 This section should provide an overall discussion of the nonclinical and clinical data
2528 and should summarise the information from various sources on different aspects of
2529 the investigational product(s), wherever possible. In this way, the investigator can be
2530 provided with the most informative interpretation of the available data and with an
2531 assessment of the implications of the information for future clinical trials.
2532 Where appropriate, the published reports on related products should be discussed.
2533 This could help the investigator to anticipate adverse drug reactions or other problems
2534 in clinical trials.
2535 The overall aim of this section is to provide the investigator with a clear understanding of the
2536 possible risks and adverse reactions and of the specific tests, observations and precautions that
2537 may be needed for a clinical trial. This understanding should be based on the available physical,
62
2538 chemical, pharmaceutical, pharmacological, toxicological and clinical information on the

2539 investigational product(s). Guidance should also be provided to the clinical investigator on the
2540 recognition and treatment of possible overdose and adverse drug reactions that is based on
2541 previous human experience and on the pharmacology of the investigational product.
63
2542 Appendix B. CLINICAL TRIAL PROTOCOL AND PROTOCOL AMENDMENT(S)

2543 Clinical trials should be described in a clear, concise and operationally feasible protocol. The
2544 protocol should be designed in such a way as to minimise unnecessary complexity and to
2545 mitigate or eliminate important risks to the rights, safety, and wellbeing of trial participants
2546 and the reliability of data. Protocol development processes should incorporate input from
2547 relevant stakeholders, where appropriate. Building adaptability into the protocol, for example,
2548 by including acceptable ranges for specific protocol provisions, can reduce the number of
2549 deviations or in some instances the requirement for a protocol amendment. Such adaptability
2550 should not adversely affect participant safety or the scientific validity of the trial. For additional
2551 information, refer to ICH E8(R1) General Considerations for Clinical Studies and ICH E9
2552 Statistical Principles for Clinical Trials.
2553 The contents of a trial protocol should generally include the following topics, which may vary
2554 depending on the trial design. Investigator site-specific information may be provided on
2555 separate protocol page(s) or addressed in a separate agreement, and some of the information
2556 listed below may be contained in other protocol referenced documents, such as an
2557 Investigator’s Brochure.
2558 B.1 General Information
2559 B.1.1 Protocol title, unique protocol identifying number, and date. Any amendment(s)
2560 should also bear the amendment number(s) and date(s).
2561 B.1.2 Name and address of the sponsor.
2562 B.1.3 Name and title of the person(s) authorised to sign the protocol and the protocol
2563 amendment(s) for the sponsor.
2564 B.2 Background Information
2565 B.2.1 Name and description of the investigational product(s).
2566 B.2.2 A summary of findings from nonclinical studies that potentially have clinical
2567 significance and from clinical trials that are relevant to the trial.
2568 B.2.3 Summary of the known and potential risks and benefits, if any, to human participants.
2569 B.2.4 Description of and justification for the route of administration, dosage, dosage
2570 regimen and treatment period(s).
2571 B.2.5 A statement that the trial will be conducted in compliance with the protocol, Good
2572 Clinical Practice (GCP) and the applicable regulatory requirement(s).
2573 B.2.6 Description of the population to be studied.
2574 B.2.7 References to literature and data that are relevant to the trial and that provide
2575 background for the trial.
2576 B.3 Trial Objectives and Purpose
2577 A clear description of the scientific objectives and the purpose of the trial. Information on
2578 estimands, where appropriate, if not included in any other trial-related document, see ICH
64
2579 E9(R1) Addendum on Estimands and Sensitivity Analysis in Clinical Trials to the Guideline
2580 on Statistical Principles for Clinical Trials.
2581 B.4 Trial Design
2582 The scientific integrity of the trial and the reliability of the results from the trial depend
2583 substantially on the trial design. A description of the trial design should include:
2584 B.4.1 A specific statement of the primary endpoints and the secondary endpoints, if any, to
2585 be measured during the trial.
2586 B.4.2 A description of the type and design of trial to be conducted (e.g., double-blind,
2587 placebo-controlled, parallel design, adaptive design, platform/umbrella/basket, trials
2588 with decentralised elements) and a schematic diagram of trial design, procedures and
2589 stages.
2590 B.4.3 A description of the measures taken to minimise/avoid bias, including:
2591 (a) Randomisation
2592 (b) Blinding
2593 B.4.4 A description of the trial treatment(s) and the dosage and dosage regimen of the
2594 investigational product(s), including a description of the dosage form, packaging and
2595 labelling.
2596 B.4.5 The expected duration of the participant’s involvement in the trial and a description
2597 of the sequence and duration of all trial periods, including follow-up, if any.
2598 B.4.6 A description of the “stopping rules” or “discontinuation criteria” and “dose
2599 adjustment” or “dose interruption” for individual participants, parts of trial and entire
2600 trial.
2601 B.4.7 Accountability procedures for the investigational product(s), including the placebo(s)
2602 and other comparator(s), if any.
2603 B.4.8 Maintenance of treatment randomisation codes and procedures for breaking codes.
2604 B.5 Selection of Participants
2605 B.5.1 Participant inclusion criteria.
2606 B.5.2 Participant exclusion criteria.
2607 B.5.3 Mechanism for pre-screening, where appropriate, and screening of participants.
2608 B.6 Withdrawal of Consent or Discontinuation of Participation
2609 The investigator may choose to discontinue the participant, or the participant may
2610 withdraw their consent. The protocol should specify:
2611 (a) when and how to discontinue participants from the trial/investigational product
2612 treatment;
65
2613 (b) the type and timing of the data to be collected for withdrawn/discontinued
2614 participants, including the process by which the data are handled, in accordance
2615 with applicable regulatory requirements;
2616 (c) whether and how participants are to be replaced;
2617 (d) the follow-up for participants who have discontinued the use of the
2618 investigational product.
2619 B.7 Treatment and Interventions for Participants
2620 B.7.1 The treatment(s) to be administered, including the name(s) of all the product(s), the
2621 dose(s), the dosing schedule(s), the criteria for dose adjustment(s), the route/mode(s)
2622 of administration and the treatment period(s), including the follow-up period(s) for
2623 participants for each investigational product treatment/trial treatment group/arm of the
2624 trial.
2625 B.7.2 Medication(s)/treatment(s) permitted (including concomitant and rescue medication)
2626 and not permitted before and/or during the trial.
2627 B.7.3 Strategies to monitor the participant’s adherence to treatment.
2628 B.8 Assessment of Efficacy
2629 B.8.1 Specification of the efficacy parameters, where applicable.
2630 B.8.2 Methods and timing for assessing, recording and analysing of efficacy parameters.
2631 Where any trial-related committees (e.g., independent data monitoring committee
2632 (IDMC)/adjudication committees) are utilised for the purpose of assessing efficacy
2633 data, procedures, timing and activities should be described in the protocol or a separate
2634 document.
2635 B.9 Assessment of Safety
2636 B.9.1 Specification of safety parameters.
2637 B.9.2 The methods, extent and timing for recording and assessing safety parameters. Where
2638 any trial-related committees (e.g., IDMC) are utilised for the purpose of assessing
2639 safety data, procedures, timing and activities should be described in the protocol or a
2640 separate document.
2641 B.9.3 Procedures for obtaining reports of and for recording and reporting adverse event and
2642 intercurrent events; see ICH E9(R1).
2643 B.9.4 The type and duration of the follow-up of participants after adverse events.
2644 B.10 Statistical Considerations
2645 B.10.1 A description of the statistical methods to be employed, including timing and purpose
2646 of any planned interim analysis(ses) and the criteria for the stopping of the trial.
2647 B.10.2 The number of participants planned to be enrolled and the reason for the choice of
2648 sample size, including reflections on or calculations of the power of the trial and
2649 clinical justification.
66
2650 B.10.3 The level of significance to be used or the threshold for success on the posterior
2651 probability in a Bayesian design.
2652 B.10.4 The criteria for the termination of the trial and the criteria for the stopping of the trial.
2653 B.10.5 The selection of participants to be included in the planned analyses (e.g., all
2654 randomised participants, all dosed participants, all eligible participants, all evaluable
2655 participants).
2656 B.10.6 Procedures for accounting for missing, unused and spurious data.
2657 B.10.7 Statement that any deviation(s) from the statistical analysis plan will be described and
2658 justified in the clinical study report.
2659 B.11 Direct Access to Source Records
2660 The sponsor should ensure that it is specified in the protocol or other documented agreement
2661 that the investigator(s)/institution(s)/service provider(s) will permit trial-related monitoring,
2662 audits, institutional review board/independent ethics committee (IRB/IEC) review and
2663 regulatory inspection(s), providing direct access to source records.
2664 B.12 Quality Control and Quality Assurance
2665 B.12.1 Description of identified quality factors and associated risks in the trial unless
2666 documented elsewhere.
2667 B.12.2 Description of the monitoring approaches that are part of the quality control process
2668 for the clinical trial.
2669 B.12.3 Description of the process for the handling of non-compliance with the protocol or
2670 GCP.
2671 B.13 Ethics
2672 Description of ethical considerations relating to the trial.
2673 B.14 Data Handling and Record Keeping
2674 B.14.1 Specification of data to be collected and the method of its collection. Where necessary,
2675 additional details should be contained in a clinical trial-related document.
2676 B.14.2 The identification of records to be recorded directly into the data acquisition tools
2677 (i.e., no prior written or electronic record of data) and considered to be source data.
2678 B.14.3 A statement that records should be retained in accordance with applicable regulatory
2679 requirements.
2680 B.15 Financing and Insurance
2681 Financing and insurance, if not addressed in a separate agreement.
2682 B.16 Publication Policy
2683 Publication policy, if not addressed in a separate agreement.
67
2684 Appendix C. ESSENTIAL RECORDS FOR THE CONDUCT OF A CLINICAL TRIAL

2685 C.1 Introduction
2686 C.1.1 Many records are generated before and during the conduct of a clinical trial. The
2687 nature and extent of those records generated and maintained are dependent upon the
2688 trial design, its conduct, application of proportional approaches and the importance
2689 and relevance of that record to the trial.
2690
2691 C.1.2 Determining which records are essential will be based upon consideration of the
2692 guidance in this appendix.
2693
2694 C.1.3 The essential records permit and contribute to the evaluation of the conduct of a trial
2695 and the reliability of the results produced. They serve to demonstrate the compliance
2696 of the investigator and sponsor with the standards of Good Clinical Practice (GCP)
2697 and applicable regulatory requirements. The essential records are used as part of the
2698 sponsor oversight or investigator supervision of the trial. These records are used by
2699 the sponsor’s independent audit function and during inspections by regulatory
2700 authority(ies) to assess the trial conduct and the reliability of the trial results. The
2701 investigator/institution should have access to and the ability to maintain and retain the
2702 essential records generated by the investigator/institution before, during and after the
2703 trial.
2704 C.2 Management of Essential Records
2705 C.2.1 Records should be identifiable and version controlled, and should include authors,
2706 reviewers and approvers as appropriate, along with date and signature (electronic or
2707 wet ink), where necessary.
2708
2709 C.2.2 For activities that are transferred or delegated to service providers by the sponsor or
2710 investigator/institution respectively, arrangements should be made for the access and
2711 management of the essential records throughout the trial and for their retention
2712 following completion of the trial.
2713
2714 C.2.3 These essential records should be maintained in or referred to from repositories,
2715 including, for example, the trial master file (TMF) or investigator site file (ISF). The
2716 TMF is held by the sponsor or by the investigator; in the latter case, it is often called
2717 the ISF.
2718
2719 C.2.4 The sponsor and investigator/institution should maintain a record of where essential
2720 records are located, including source records. The storage system(s) used during the
2721 trial and for archiving (irrespective of the type of media used) should provide for
2722 appropriate identification, version history, search and retrieval of trial records.
2723
2724 C.2.5 The sponsor and investigator/institution should ensure that the essential records are
2725 collected and filed in a timely manner, including those required to be in place prior to
2726 the trial start, which can greatly assist in the successful management of a trial.
68
2727 C.2.6 The sponsor and investigator/institution should retain the essential records in a way
2728 that ensures that they remain complete, readable and readily available and are directly
2729 accessible upon request by regulatory authorities. Alteration to the essential records
2730 should be traceable.
2731
2732 C.2.7 The original version of the essential record should be retained by the responsible party
2733 (sponsor or investigator). When a copy is used to permanently replace the original
2734 essential record, the copy should fulfil the requirements for certified copies.
2735
2736 C.2.8 In order to fulfil their responsibilities in the conduct of the trial, the sponsor and
2737 investigator/institution may need access to or copies of one another’s relevant
2738 essential records before, during and after the trial is completed. This will determine
2739 whether the record resides in the repositories of the sponsor, the
2740 investigator/institution, or both. There should be careful consideration of sharing of
2741 records subject to data protection legislation and blinding considerations in line with
2742 applicable regulatory requirements. For the sharing of essential records with service
2743 providers, see section C.2.2.
2744
2745 C.2.9 Certain essential records may not be specific to a trial but may be related to the
2746 systems and processes involved in running multiple trials and retained outside the
2747 trial-specific repositories (e.g., standard operating procedures validation records,
2748 master services agreements).
2749 C.3 Essentiality of Trial Records
2750 C.3.1 Whether a specific clinical trial record generated before, during and after the trial is
2751 essential and needs to be retained should be based on the following criteria:
2752 (a) Is a document that is submitted to or issued by the regulatory authority or
2753 IRB/IEC, including related correspondence and those documenting regulatory
2754 decisions or approvals/favourable opinions;
2755 (b) Is a trial-specific procedure or plan;
2756 (c) Is relevant correspondence or documentation of meetings related to important
2757 discussions and/or trial-related decisions that have been made related to the
2758 conduct of the trial and the processes being used;
2759 (d) Documents the conduct of relevant trial procedures;
2760 (e) Documents the arrangements between parties and insurance/indemnity
2761 arrangements;
2762 (f) Documents the compliance with the requirements and any conditions of
2763 approval from the regulatory authority or the favourable opinion of the
2764 institutional review board/independent ethics committee (IRB/IEC);
2765 (g) Documents the composition and, where appropriate, the functions,
2766 correspondence and decisions of any committees involved in the trial approval
2767 or its conduct.
69
2768 (h) Demonstrates that a trial-specific computerised system is validated and that
2769 non-trial-specific systems have been assessed as fit for purpose for their
2770 intended use in the trial;
2771 (i) Is a document that has been authorised/signed by the sponsor and/or
2772 investigator to confirm review or approval;
2773 (j) Is, where necessary, documentation that demonstrates signatures/initials of staff
2774 undertaking trial-specific activities; for example, completing data acquisition
2775 tools;
2776 (k) Documents what information was provided to potential trial participants and
2777 that participants’ informed consent was appropriately obtained and maintained;
2778 (l) Documents that sponsor personnel involved in the trial conduct and individuals
2779 performing trial-specific activities on their behalf are qualified by education,
2780 training and experience to undertake their activities;
2781 (m) Documents that the investigator and those individuals delegated trial-specific
2782 activities by the investigator are qualified by education, training and experience
2783 to undertake their activities, particularly where the activities are not part of their
2784 normal role;
2785 (n) Contains the data as well as relevant metadata that would be needed to be able
2786 to reconstruct the trial;
2787 (o) Are documents related to the sponsor and investigator oversight of safety of
2788 trial participants during the trial, including compliance with safety reporting
2789 requirements between sponsors and investigators, regulatory authorities and
2790 IRBs/IECs and informing trial participants of safety information as necessary;
2791 (p) Documents that service providers are suitably qualified for conducting their
2792 delegated or transferred activities;
2793 (q) Documents that laboratory activities and other tests used in the trial are fit for
2794 purpose;
2795 (r) Documents sponsor oversight of investigator site selection and monitoring and
2796 audit of the trial, where appropriate, and provides information on arising
2797 issues/non-compliance and deviations detected and implementation of
2798 corrective and preventative actions;
2799 (s) Documents the compliance with the protocol and/or procedures for
2800 management and statistical analysis of the data and production of any interim
2801 report and the final report;
2802 (t) Documents the collection, chain of custody, analysis and retention or
2803 destruction of biological samples;
2804 (u) Provides relevant information on the investigational product and its labelling;
2805 (v) Provides information about the shipment, storage, packaging, dispensing,
2806 randomisation and blinding of the investigational product;
2807 (w) Provides, where appropriate, traceability and accountability information about
2808 the investigational product from release from the manufacturer to dispensation,
70
2809 administration to trial participants, and return and destruction, or alternative

2810 disposition;
2811 (x) Provides information on the identity and quality of the investigational product
2812 used in the trial;
2813 (y) Documents processes and activities relating to unblinding;
2814 (z) Documents the recruitment, pre-trial screening and consenting process of trial
2815 participants and their identity and chronological enrolment as appropriate;
2816 (aa) Documents the existence of the trial participants and substantiates the integrity
2817 of trial data collected. Includes source records related to the trial and medical
2818 treatments and history of the trial participants;
2819 (bb) Defines processes/practices in place in the event of a security breach in order to
2820 protect participants’ rights, safety and well-being and the integrity of the data.
2821 C.3.2 Applying the criteria in section C.3.1, the trial records for every trial that are
2822 considered essential, except in justifiable and documented exceptional circumstances,
2823 are set out in Table 1, and these should be retained.
2824
2825 C.3.3 For other trial records, their presence and nature are dependent upon the trial design,
2826 its conduct and risk proportional management. Table 2 lists potential trial records that
2827 when generated, would be considered essential by applying the criteria in section
2828 C.3.1 and should be retained. This is not an exhaustive list, and other trial records may
2829 also be considered essential by the sponsor or the investigator.
2830
Table 1 – Essential Records for All Trials
1.1 Investigator’s Brochure or basic product information brochure (e.g., summary of
product characteristic, package leaflet or labelling) and relevant updates
1.2 signed protocol and amendments during the trial
1.3 dated, documented approval/favourable opinion of IRB/IEC of information provided
to them before and during the trial
1.4 IRB/IEC composition
1.5 regulatory authority(ies) authorisation, approval and/or notification of the protocol
and subsequent protocol amendments during the trial (where required)
1.6 completed signed and dated informed consent forms
1.7 completed participant identification code list and enrolment log
1.8 - notification by originating investigator to sponsor of serious adverse events (SAEs)
and related reports, where required
- notification by sponsor and/or investigator, where required, to regulatory
authority(ies) and IRB(s)/IEC(s) of suspected unexpected serious adverse reactions
(SUSARs) and of other safety information
- notification by sponsor to investigators of safety information, where required
1.9 interim or annual reports to IRB/IEC and regulatory authority(ies)
1.10 source records
71
Table 1 – Essential Records for All Trials

1.11 data and relevant metadata (including documentation of data corrections) in the data
acquisition tools
1.12 final report by investigator to IRB/IEC and regulatory authority(ies), where required
1.13 interim (where applicable) and final clinical trial reports
2831
Table 2 – Potential Essential Records
2.1 sample of data acquisition tools (e.g., case report forms (CRFs), diaries, clinical
outcome assessments, patient-reported outcomes) that are provided to the investigator
and/or IRB/IEC
sample of information given to trial participants and revisions during the trial
2.2 - informed consent materials (including all applicable translations)
- any other documented information, e.g., instructions for use of an investigational
product or a device
- advertisement for participant recruitment
2.3 financial aspects of the trial
2.4 insurance statement
2.5 signed agreement between involved parties, e.g.,
- investigator/institution and sponsor
- investigator/institution and service providers
- sponsor and service providers
- sponsor and independent data monitoring committee (IDMC) members
2.6 curriculum vitae and/or other relevant documents evidencing qualifications of
investigator(s) and sub-investigator(s) involved in conducting the trial
2.7 trial-specific training records
2.8 documentation of delegation of activities by the investigator to investigator site staff
2.9 signature sheet documenting signatures and initials of delegated investigator site staff
2.10 normal value(s)/range(s) for medical/laboratory/technical procedure(s) and/or test(s)
included in the protocol and updates during the trial conduct
2.11 certification or accreditation or established quality control and/or external quality
assessment or other validation (where required) of medical/laboratory/technical
procedures/tests used during the trial conduct and any updates
2.12 documentation of collection, processing and shipment of body fluids/tissue samples
2.13 documentation of body fluids/tissue samples storage conditions
2.14 record of retained body fluids/tissue samples at the end of the trial
2.15 sample of label(s) attached to investigational product container(s)
2.16 instructions for handling of investigational product(s) and trial-related materials (if
not included in protocol or Investigator’s Brochure), for example, pharmacy manual
2.17 shipping records for investigational product(s) and trial-related materials
2.18 certificate(s) of analysis of investigational product(s) shipped
72
Table 2 – Potential Essential Records

2.19 investigational product(s) accountability at investigator site
2.20 documentation of investigational product storage conditions during shipment and at
the trial site
2.21 records of relabelling of investigational product at trial site
2.22 documentation of investigational product destruction
2.23 emergency decoding procedures for blinded trials
2.24 master randomisation list
2.25 instructions for use for critical trial-specific systems (e.g., interactive response
technologies (IRT) user manual, electronic CRF (eCRF) manual)
2.26 maintenance and calibration records for critical trial-specific equipment
2.27 treatment allocation and decoding documentation
2.28 completed participants screening log
2.29 site monitoring reports (including site selection, initiation, routine and close-out)
2.30 centralised monitoring reports
2.31 records and reports of protocol and GCP non-compliance/deviations and corrective
and preventative actions
2.32 documentation of relevant communications and meetings
2.33 audit certificate
2.34 documentation relating to data finalisation for analysis (e.g., query resolutions, SAE
reconciliation, quality control reports, coding completion, output data sets)
2.35 documentation of trial-specific computerised system validation (e.g., specifications,
testing, validation report, change control)
2.36 documentation relating to the statistical considerations and analysis (e.g., sample size
calculations, analysis sets decisions, analysis datasets, analysis programs, quality
control records and output)
2.37 trial-specific plans (e.g., risk management, monitoring, safety, data management, data
validation and statistical analysis) and procedures
2.38 procedures, meeting minutes and submissions to the IDMC
2832
73

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25 May 2023

ICH E6 (R3) Guideline on good clinical practice (GCP)

Transmission to CHMP 25 May 2023

Adoption by CHMP 25 May 2023

Release for public consultation 26 May 2023

Deadline for comments 26 September 2023

Official address Domenico Scarlattilaan 6 ● 1083 HS Amsterdam ● The Netherlands

ICH HARMONISED GUIDELINE

GOOD CLINICAL PRACTICE (GCP)

Currently under public consultation

ICH HARMONISED GUIDELINE

GOOD CLINICAL PRACTICE (GCP)

3.15.3 Supplying and Handling Investigational Product(s) ................................. 36

A.2.2 Confidentiality Statement .......................................................................... 59

35 II. PRINCIPLES OF ICH GCP

123 informed consent process should be clear and concise so as to be understandable

258 11.4 Manufacturing, handling and labelling of investigational products should be

345 1.2 Composition, Functions and Operations

431 1.5 Submission and Communication

559 The investigator/institution should inform a participant when medical care is

649 to the satisfaction of the participant or the participant’s legally acceptable

957 3.5 Financing

1046 3.8.2 Confirmation of Review by IRB/IEC

1131 Risk mitigation activities may be incorporated in protocol design and

1170 3.11.2.1 Selection and Qualification of Auditors

1254 3.11.4.3 Monitoring Plan

1296 3.11.4.5.2 Investigator Site Selection, Initiation, Management and Close-out

1470 (f) Alternative arrangements for safety reporting to regulatory authorities,

1729 3.16.2 Statistical Programming and Data Analysis

1813 4. DATA GOVERNANCE – INVESTIGATOR AND SPONSOR

1854 4.2 Data Life Cycle Elements

1893 4.2.3 Review of Data and Metadata

2018 4.8 User Management

2107 Certified Copy

2143 Data Acquisition Tool (DAT)

2182 Informed Consent

2257 Original Medical Record

2292 Source Records

2378 A.2 General Considerations

2538 chemical, pharmaceutical, pharmacological, toxicological and clinical information on the

2542 Appendix B. CLINICAL TRIAL PROTOCOL AND PROTOCOL AMENDMENT(S)

2684 Appendix C. ESSENTIAL RECORDS FOR THE CONDUCT OF A CLINICAL TRIAL

2809 administration to trial participants, and return and destruction, or alternative

Table 1 – Essential Records for All Trials

Table 2 – Potential Essential Records

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