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Standard Operating Procedure for Archiving

Essential Documentation relating to Clinical
Trials of Investigational Medicinal Products
(CTIMPs)

SOP ID Number: JRO/SPON/S21/02

Effective Date:
01/04/2012

Version Number & Date of Authorisation: V02, 28/03/2012

Review Date:
01/04/2014

eDocument kept:

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Revision Chronology:

SOP ID Number:

Effective
Date:

JBRU/SPON/S21/01

15/02/10

JRO/SPON/S21/02

Routine
review
Change
01/04/2012 terminology,
change
department name

Reason for Change:

ACRONYMS:
JRO
Joint Research Office
GCP
SOP
CI
PI
TMF
ISF
MHRA
REC
QA

Good Clinical Practice

Standard Operating Procedure
Chief Investigator
Principal Investigator
Trial Master File
Investigator Site File
Medicines and Healthcare Products Regulatory Agency
Research Ethics Committee
Quality Assurance

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Author:
Dave Wilson
in
Daniel
of
Heather

www.ucl.ac.uk/jro/

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Standard Operating Procedure for Archiving Essential

Documentation relating to Clinical Trials of Investigational
Medicinal Products (CTIMPs)
1. PURPOSE
This Standard Operating Procedure (SOP) has been written to describe the procedure
for the archiving of essential documents relating to the management of clinical trials of
investigational medicinal products (CTIMPs) as defined by the Medicines for Human
Use (Clinical Trials) Regulations 2004 [SI 2004/1031] and in accordance with local
UCL policy on records retention, management and archiving.

2. JOINT UCL/UCLH/RF RESEARCH OFFICE POLICY

All SOPs produced from the JRO must be used in conjunction with local NHS Trusts
and UCL policies and procedures.
The JRO acts as the representative of the Sponsor and will be the official name used
on all SOPs.

3. BACKGROUND
All SOPs are written in accordance with applicable GCP requirements as outlined in
Directives 2001/20/EC and 2005/20/EC (in the UK, these Directives were transposed
into UK law by SI 2004/1031, SI 2006/1928) and subsequent amendments and where
applicable incorporates elements of ICH GCP tripartite guidelines (E6).
The EU GCP Directive 2005/28/EC and subsequent enabling legislation set out the
standard for archiving clinical trials essential documentation. As public funded CTIMPs
need to meet UK regulatory standards set by the appropriate competent authority the
Medicines and Healthcare products Regulatory Agency (MHRA), it is necessary for
there to be a robust and secure archiving system to be in place for all essential
documentation managed by the JRO at the end of the life of a CTIMP.

4. SCOPE OF THIS SOP

This SOP covers the archiving of JRO Sponsor Files for CTIMPs sponsored by UCL
and managed by the JRO.
Further details as to the operation of the UCL Archiving System is shown in Appendix
1. UCL Records Management Service (How to transfer records) is replicated in
Appendix 2.

5. RESPONSIBLE PERSONNEL
The JRO R&D Record Manager maintains oversight for the archiving of all documents
relating to CTIMPs within the JRO. The physical listing and transfer of records will be
delegated to the UCL CTIMP/Admin. team where appropriate. The responsible
archivist for UCL is the UCL Records Manager based within UCL Records Office. The
JRO is responsible for presenting the paper JRO sponsor file to the R&D Record
Manager for archiving. The named archivist for UCL is Mr Colin Penman (UCL Records
Officer).

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6. PROCEDURE
6.1 Storage and archiving
To ensure that results from CTIMPs can be examined and subject to internal and
regulatory audit, it is necessary that both Sponsor and Chief Investigator keep records
of the clinical trial throughout its life cycle at site that are capable of being archived.
Archiving of investigator site files as part of a multi-centre CTIMP will be determined by
local site guidance and policy and regulatory requirements.
A paper sponsor file is ready for archiving when the Chief Investigator of a CTIMP
informs the JRO that the End of Trial Study Report has been submitted to the
MHRA. This report is required within one year of formal notification of end of
Clinical Trial to Research Ethics Committee and MHRA.
All essential documents held within the JRO Sponsor file are appropriately archived
through the transfer of records to the UCL Records Office using the Records Office
Database in Citrix Program Neighbourhood. Records are stored securely at UCLs
external archiving repository based at Wickford in Essex. A log of documents archived
is kept within UCL Records Office.
6.2 Retention Policy
In accordance with UCL Records Management Policy, research findings will need to be
stored by UCL as sponsor for 20 years after the research has finished based on
recommendations made in the Medical Research Councils Ethics Series on Good
Clinical Practice. This is deemed a sufficient period of time to allow for audit and
inspections by regulatory authorities. The UCL Records Office provides a service to
UCL staff and maintains archived records in a safe and secure off site location. All
activities are conducted in accordance with the Data Protection Act and UCL Data
Protection Policy. Access to the data is strongly regulated and permissions to access
the data are treated case by case. The Records Office allows for records to be
catalogued onto an online database, and assists in recalling archives on demand.
In addition clinical trials of Advanced Therapy Investigational Medicinal Products
(ATIMP) are subject to the traceability requirements set-out in the Advanced Therapy
Medicinal Product Regulation (EC) No 1394/2007 transposed in UK law by SI
2010/1882. In line with this legislation, the Sponsor (or delegate) and investigator trial
site administering the ATIMP to patients must retain relevant records relating to
product traceability for at least 30 years after the expiry date of the product.
The European Commission guidance Detailed guidelines on good clinical practice
specific to advanced therapy medicinal products sets out the traceability records and
minimum data set the Sponsor, investigator and institutions responsible for human
application of ATIMP must retain for the minimum 30 year period.

6.3 Chief investigator TMF.

It is the responsibility of the Chief Investigator to archive his/her TMF using the UCL
archiving facilities. He/she will carry out a TMF review using the TMF review template
and email this document to the JRO together with the document detailing where
his/her file has been archived. This document will be kept in the JRO sponsor
file.

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6.4 Investigator Site File

In a multi-centre clinical trial it will be the responsibility for each investigator site to
arrange its own archiving of CTIMP records in paper and electronic form, in
accordance with local policy and guidelines. Sponsor oversight of the content of the
site file is captured as part of the end of trial SOP.
6.5 Pharmacy file
Pharmacies will be responsible for arranging their own pharmacy file archiving. The
Principal Investigator will have a file note in the Investigator Site File outlining
where the trial Pharmacy file is archived.
For both investigator site file and Pharmacy site file, the Principal Investigator will email
the Chief Investigator to let him know where his files have been archived.

7. REFERENCES

Medicines for Human Use (Clinical Trials) Regulations 2004 [SI 2004/1031]
Section 8 of ICH Harmonised Tripartite Guideline for Good Clinical Practice (1996)
Medical Research Council Ethics Series on Good Clinical Practice
EU GCP Directive 2005/28/EC
Data Protection Act 1998
Advanced Therapy Medicinal Product Regulation (EC) No 1394/2007
The Medicines for Human Use (Advanced Therapy Medicinal Product and
Miscellaneous Amendments) Regulations 2010 [SI 2010/1882]
Detailed guidelines on good clinical practice specific to advanced therapy medicinal
products [ENTR/F/2/SF/dn D(2009) 35810]

REFERENCED GUIDES / SOPs

All SOPs, Policies, Procedures and Guidance produced by JRO

UCL Records Policy

http://www.ucl.ac.uk/joint-rd-unit
COMMISSION DIRECTIVE 2005/28/EC of 8 April 2005 laying down principles and
detailed guidelines for good clinical practice as regards investigational medicinal
products for human use, as well as the requirements for authorisation of the
manufacturing or importation of such products.

8. APPENDICES
Appendix 1: UCL
Neighbourhood)

Records

Office

Archiving

System

(Citrix

Program

First step: Registration for access to the Records Office System

Go to:
http://www.ucl.ac.uk/isd/staff/admin_systems/student_systems/registration/#forms
Then click on the link Records Office Archiving listed in the table under Registration
Forms.
This will open a word document, this form must be filled in and signed in order to gain
access to the records office.
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Then follow instructions below;

Instructions for completion of form:
Sections 1 and 2: to be completed by, or on behalf of, the user.
Section 3 to be completed by the Records Office.
User retains a copy
The signed form should then be returned to Database Registrations,
Management Systems, 1-19 Torrington Place
1) To logon to Archive Database
Enter the following URL in web browser:
www.ucl.ac.uk/management-systems/msapps/otheradminsystems
[This link takes you into UCL Information Services Division - Management Services].
Click onto live system (not old version)
[MS log on & GEN
2) Procedure for archiving
Login using normal IS username and IS p/w
Records Office
- Departmental users
- Clients data entry
takes you into Data Entry screen
Click New Box [Cursor will be at reference and be yellow in colour].
Put in reference (format UCLH R&D BOX xxx) [taken from archives feeder
spreadsheet maintained by Chris Lord]
Click into File title
Enter UCLH ID and Title [again from spreadsheet]
Tip: To copy titles, use Ctrl C and Ctrl V to cut and paste from s/sheet to Data entry
screen.
Enter File type by clicking grey square and selecting 2 (Research) from the drop
down list [this will apply only for the first record of each new box only]
Click ok
From Dateand Last Date put current month/year in the example format Oct-2008
Press F10 and OK to save record.
Note that:
Item number will now be saved.

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Box No reference will be automatically generated by the system (e.g. UCLH/2008/93).It

is THIS reference that is written on the side of the archive box under Box No. before
shipping to UCL Records Office.
To go to second item within the same Box reference:
Press green + sign to add a record [note that Item no. automatically changes to next
consecutive number].
Repeat process until all projects listed on s/sheet under the relevant box number
reference, have been entered up onto records system.
Annotate the feeder spreadsheet with the automatic generated Box No. reference.
______________________________________________________________
To enter a brand NEW Record (i.e. a new box)
Click New Box and repeat stages as above.

3) Making changes to saved entries

2.1 Enter query by clicking the ? icon in the tool box
[Box number field goes green]
2.2 Enter the auto-generated UCLH archive reference e.g.UCLH/2008/188
2.3 Press F8 to bring up record
2.4 Make changes by clicking into field (normally this is ever going to be the title field)
2.5 Press F10 to save changes
-------------------------------------------------------------------------------------4) Checking entries made
Repeat process above up to 2.3
Click into title field
Use the forward blue forward arrow in the tool bar to go through records entered for
given Box no.
If any entries need amending, make changes and press F10
Go to next Box no.
Legend:
F10 = Execute
F8 = Query
F4 = Brings back previous record
Ctrl C copies record from spreadsheet
Ctrl V pastes record into archives system (name?)
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Location WD is entered by UCL Records Office and contained in the Box List
prepared and sent to JBRU by UCL Records Office
+ green = new record
Appendix 2 UCL Records Management Service, How to transfer Records
The Records Office provides the Records Management Services for the whole of UCL.
The Records Management Policy, which was confirmed as a UCL Policy in 1999,
applies to all administrative records, whatever their format:
http://www.ucl.ac.uk/efd/recordsoffice/policy/
All Institutes, Departments and Schools within UCL are expected to consult the
Records Manager before disposing of non-current records.
Please follow these simple guidelines every time you want to transfer your
department's records to the Records Office. This will help us to help you to manage
your records correctly. There is no charge for use of this service.
Using
the
Database
We control management of records through the Records Office database. You can
describe your records on this database whenever you want to make a transfer.
When you contact us we will check that you have signed up to the database. If not, we
will arrange to provide you an account, give you access, and arrange training. The
training module provides technical detail on how to operate the system. It will also
provide instruction on what information should be held.
Method
of
Storage
Please use the boxes supplied by the Records Office for transferring your records. We
supply these as flat packs free. Please contact the Records Office to request the
number
of
boxes
you
need.
We use 2 box types:

CAS 5 - Transfer File Box

This is our standard Document Box with an Integral Lid.
360mm
(L)
x
140mm
(H)
x
255mm
Weight
limit:
8
kg.
or in special circumstances and only after agreement with the Records Office:

(W)

CAS 4 - Archive Box

Treble
Heavyweight
380mm
(L)

Wall
&
260mm

Thickness
(H)

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Secure
x

280mm

(W)

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Weight
limit:
Packing the boxes

10

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kg.

Be careful not to overfill the box and keep the handles clear.

Weight limits: We have been advised by the Library Services Health and
Safety Officer that the weight limit for boxes should be as follows:
o

Small CAS5 boxes must not weigh more than 8kg.

Large CAS4 boxes must not weigh more than 10kg.

Please
note:
1. These limits are also necessary to meet the weight limits of the shelves in the library
store.
2. Over weight boxes will be returned to the user department for repacking.

Ring binders can be wasteful of space and, ideally, should not be put into
boxes. Please remove the contents and put them into a file wallet, carefully
writing the title and dates of the file on the outside.

Please print off a box list and put it into the box.

Please write the box no generated from the database system onto the box. We
will give them the full numbers in the Records Office.

Storage
of
items
other
than
paper:
Please advise the Records Office that you are intending to store items other than
paper, such as electronic material or photographic material in the boxes provided. We
can advise you of any issues that may need to be addressed.
We will also ensure that the boxes are stored in a suitable area to protect the media.
Collection
When you have completed listing and packing your records, please telephone the
Records Office and we will arrange for the College Porters to collect the boxes and
bring them to the Records Office for checking. At the checking stage, we may find
some boxes are badly packed or too heavy. In such cases we will contact you to find a
way
to
resolve
the
situation.
N.B. Please DO NOT contact the Estates & Facilities Help Desk for collection.
This must be arranged with the Records Office.
Records
Office
Administration
On arrival in the Records Office we check the contents of the boxes against the data
entered into the database and issue identifying department and shelf numbers, for the
store.
We then print off a box list with the full references and post it to the department. Please
check that you have received a box list for every box that you have deposited and that
the information is correct. It is your responsibility to contact the Records Office
immediately if there is a discrepancy.
Records
Retrieval
The database training module will instruct you how to retrieve records from storage.
The requested records will be returned to the Records Office by 2pm on the following
working day. You will be notified as soon as the records arrive. We would prefer that
you collect the records in person, but if you're unable to do this please call us and we
can
make
alternative
arrangements.
If you wish to retain items retrieved permanently, please advise the Records Office so
we can update the database.
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Destruction
Policy
All records should be retained or disposed of according to UCL retention schedules
and appraisal guidelines established by the Records Management Programme. These
are published separately and copies can be obtained from the Records Manager.
When a box is sent to the Records Store a retention period is assigned to the
box. The Records Office will contact you when the retention period has been
reached to obtain approval to destroy the records. No records will be destroyed
without your approval.
Other
Services:
Short
Term
Storage
In special circumstances and only after agreement with the Records Office, we can
accommodate items into the Records Management Service for short-term storage,
(e.g.: up to two years), while Departments are relocated. The standard guidelines for
transfer of records to the store must be adhered to.
Contacts
at
the
All
Record
Office
staff
can
provide
Our
collective
mailbox
is:

Records
Office
you
with
general
advice.
records.office@ucl.ac.uk.

Contacts:

TO UPDATE (e.g. c.penman@ucl.ac.uk; r.winkworth@ucl.ac.uk)

9. TEMPLATES/LOGS ASSOCIATED TO THIS SOP

1
2
3

Appendix 1
List of Essential Documents in the JBRU sponsor file, CI Trial
Master File
Appendix 2
Operation of the UCL Archiving System (Citrix Program
Neighbourhood)
Appendix 3
UCL Records Management Service How to transfer records

10. SOP DISSEMINATION AND TRAINING

New SOPs will be distributed to the concerned staff, by the named author on the front
page of the SOP. Staff concerned by the SOP will sign the SOP training log (12. SOP
TRAINING LOG) which is part of each SOP. In addition, each staff should have an
Individual Staff SOP and courses log (template available in the TO UPDATE website)
and will need to update it once trained on the SOP.
The training will constitute of the person reading the SOP and being provided with the
opportunity to ask specific questions to the author of the SOP.
The website link to JRO SOPs is sent to the investigators as soon as the JRO is aware
of the trial being set up.
The website link to new SOPs relevant to JRO staff and investigators or investigators
only will be emailed to the investigators by the author of the SOP. The investigators will
be requested to read the new SOP and email back to acknowledge receipt and
understanding of the new SOP. The email sent to the investigators and their emails
acknowledging receipt and understanding of the SOP should be printed out and filed in
the JRO SOP folder together with the relevant SOP.
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11. SIGNATURE PAGE

Daniel Heather,
Author and Job Title:
JRO R&D Record Manager
Signature:

Date:

Authorised by:
Name and Job Title

Helen Cadiou, Quality Assurance Manager

Signature:

Date:

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12. SOP TRAINING LOG

Job Title:

Name of Staff (Capital letters)

Department:

Training
Date

I confirm that
I
understand & agree
to work to this SOP
SIGNATURE

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Name of Trainer (if training

required)

Signature

Date

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Job Title:

Name of Staff (Capital letters)

Department:

Name of Staff (Capital letters)

Job Title:
Department:

Training
Date
Training
Date

I confirm that
I
understand & agree
to work to this SOP
SIGNATURE
I confirm that
I
understand & agree to
work to this SOP
SIGNATURE

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Name of Trainer (if training

required)
Name of Trainer (if training
required)

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Signature
Signature

Date

Date