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Curriculum Vitae Investigator Site Staff

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1.0 INSTRUCTIONS
This form can be used for 2 purposes:
For investigators to record relevant CV information (e.g. in case they do not have
an appropriate CV available). The investigator will have to sign and date the
completed CV.
For Quintiles staff to transcribe information from a non-English investigator CV.
In such a case it is not required for the investigator to sign and date the
completed form as a signed and dated original CV in local language is already
available.
Only complete page 3 of this form as appropriate for abbreviated translation of nonEnglish Curriculum Vitae by Quintiles staff.
Do not print this instruction page when printing the completed form.
1.4

Statement of Education and Qualifications

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1.6 PLEASE PRINT OR TYPE THE FOLLOWING INFORMATION:

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1.9 Academic Qualification(s) (e.g.

MD, MBBS, Medical License Number,
etc)

1.8 Name (First, Middle, Last)

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Ridha Surya Nugraha

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Address (Name of Institution, Street, City, Postal Code, State or Province (if applicable),

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MD

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Country)

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Rumah Sakit dr. Cipto Mangunkusumo

Subbagian Endokrinologi dan Metabolik, Departemen Penyakit Dalam
Jln. Diponegoro No. 71
Jakarta, Indonesia
10430

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Telephone Number (Country Code,

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Area Code, Number)

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62 21 3907703

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FAX Number (Country Code,

Area Code, Number)

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62 21 3928659

Email Address
dr.ridhasurya@gmail.com

Education and Training (List all Colleges, Universities and Medical Schools attended,
postdoctoral/fellowship training, board certification/medical license)

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Name and Location of
Institution
(City, State or Province and Country)

Form No: CS_FM_ISS0225 Revision 1

Effective Date: 01Sep2013

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Degree
and Year
Awarded

1.41
Are
a of
Study

Reference: CS_WI_ISS0220

Copyright 2013 Quintiles Transnational Corp. All rights reserved. The contents of this document are Confidential and Proprietary

Page 2 of 2

Form Title
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Faculty
of
Medicine,
Universitas Jendral Achmad Yani,
Cimahi, West Java, Indonesia
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2013

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Ge
neral
Practio
ner
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Professional
Experience

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Dat
es

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Name and Location
of Institution
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1.68 (City, State or Province and

Country)

Position/Title

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dr.
Mangunkusumo
Hospital

1.71 Current

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Staff endocrinology
Departemen (Assistant)
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1.76 Previous

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Doctor Internsip

1.70 (Start/Sto
p Dates
as
applicabl
e)

Cipto
General

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201
4- Now

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Ujung
Berung
Hospital, Bandung City,
West Java, Indonesia
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1.80
201
3
2014
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Previous participation in clinical trials

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Indication
of Trial
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Form No: CS_FM_ISS0225 Revision 1
Effective Date: 01Sep2013

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C
lini
cal
Pha
se
of
Tria
l (IIV)
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Y
ear
in
whi
ch
trial
was
con
duc
ted
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Role in Trial

(e.g. Investigator,
Sub-Investigator)

Reference: CS_WI_ISS0220

Copyright 2013 Quintiles Transnational Corp. All rights reserved. The contents of this document are Confidential and Proprietary
to Quintiles Transnational Corp. Unauthorized use, disclosure or reproduction is strictly prohibited.

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Training on ICH/GCP: YES

If yes, specify below

NO

1.119 Document type of training and year when training was conducted
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1.126 Other documents evidencing experience or expertise attached:
YES
If yes, specify below
NO
v
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Signature (if required)

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Date

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FOR QUINTILES USE ONLY

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1.143 For Abbreviated Translation of non-English Curriculum Vitae by Quintiles staff,
complete below:
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Not applicable (If not applicable leave the rest of this page blank)
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1.147 I hereby certify that to the best of my knowledge, the English text of this document
represents an adequate translation of the original text provided.
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1.149 Translator Signature
1.150 Date
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1.156 Translator Printed Name (First Name, Last Name, Job Title and (Academic) Qualification(s))
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1.161 Translator Address (Quintiles Office Name, Street, City, Postal Code, State or Province (if
applicable), Country)

Copyright 2013 Quintiles Transnational Corp. All rights reserved. The contents of this document are Confidential and Proprietary
to Quintiles Transnational Corp. Unauthorized use, disclosure or reproduction is strictly prohibited.

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Copyright 2013 Quintiles Transnational Corp. All rights reserved. The contents of this document are Confidential and Proprietary
to Quintiles Transnational Corp. Unauthorized use, disclosure or reproduction is strictly prohibited.