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“headline”: “SOP for TMF Access, Permissions, and Security”,
“description”: “This SOP outlines standardized procedures for managing access, permissions, and security for Trial Master Files (TMF/eTMF), ensuring compliance with ICH GCP, FDA, EMA, CDSCO, and WHO requirements. It covers user roles, authentication, password policies, inspector access, and access control logs.”,
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Published on 21/12/2025
Standard Operating Procedure for TMF Access, Permissions, and Security
| SOP No. | CR/OPS/079/2025 |
| Supersedes | NA |
| Page No. | 1 of 38 |
| Issue Date | 26/08/2025 |
| Effective Date | 01/09/2025 |
| Review Date | 01/09/2026 |
Purpose
The purpose of this SOP is to define processes for managing access, permissions, and security of Trial Master Files (TMF/eTMF), ensuring
Scope
This SOP applies to all sponsor, CRO, site, and vendor staff accessing TMF/eTMF systems. It covers user role assignment, authentication, inspector access, account lifecycle management, password and security policies, access logging, and oversight responsibilities.
Responsibilities
- Sponsor: Owns responsibility for TMF/eTMF access policies and oversight.
- TMF Administrator: Assigns roles, manages permissions, monitors access logs.
- IT/System Administrator: Maintains system security, authentication controls, and audit trails.
- QA: Audits TMF access practices for compliance.
- Users: Maintain confidentiality, follow password and access policies, and report incidents.
Accountability
Head of QA is accountable for overall TMF/eTMF security and compliance. TMF Administrator is accountable for user access accuracy and timeliness. IT is accountable for system security controls.
Procedure
1. User Role Definition
1.1 Define TMF user roles (Admin, Contributor, Reviewer, Read-only).
1.2 Maintain TMF Permission Matrix (Annexure-1).
1.3 Assign access based on “least privilege” principle.
2. Access Requests
2.1 Users submit Access Request Form (Annexure-2).
2.2 Requests approved by line manager and QA.
2.3 TMF Administrator assigns access within 2 working days.
3. Authentication Controls
3.1 All accounts must have unique usernames and strong passwords (minimum 8 characters, complexity requirements).
3.2 Multi-factor authentication (MFA) must be enabled for remote access.
3.3 Passwords expire every 90 days and must not be reused for 5 cycles.
4. Inspector Access
4.1 Regulatory inspectors may be granted read-only access during inspections.
4.2 Access must be time-bound and logged in Inspector Access Log (Annexure-3).
4.3 Inspector accounts must be deactivated immediately after inspection closure.
5. Account Lifecycle Management
5.1 Accounts must be reviewed every 6 months.
5.2 Access must be revoked within 1 working day of employee leaving project.
5.3 All account changes logged in Access Control Log (Annexure-4).
6. Access Monitoring
6.1 IT and QA review access logs monthly.
6.2 Suspicious access attempts must be investigated within 24 hours.
6.3 Findings documented in Security Incident Log (Annexure-5).
7. Confidentiality and Security
7.1 All users must sign confidentiality agreements.
7.2 Data exports must be encrypted and logged.
7.3 Unauthorized access attempts result in account suspension.
Abbreviations
- SOP: Standard Operating Procedure
- TMF/eTMF: Trial Master File / electronic Trial Master File
- QA: Quality Assurance
- IT: Information Technology
- MFA: Multi-Factor Authentication
Documents
- TMF Permission Matrix (Annexure-1)
- Access Request Form (Annexure-2)
- Inspector Access Log (Annexure-3)
- Access Control Log (Annexure-4)
- Security Incident Log (Annexure-5)
References
- ICH E6(R2/R3) – Essential Documents and Systems
- FDA – 21 CFR Part 11 Guidance
- EMA Annex 11 – Computerized Systems
- CDSCO – Clinical Trial Requirements
- WHO – Data Security in Clinical Trials
Version: 1.0
Approval Section
| Prepared By | Ravi Kumar, TMF Administrator |
| Checked By | Sunita Reddy, QA Officer |
| Approved By | Dr. Anil Sharma, Head Clinical Quality |
Annexures
Annexure-1: TMF Permission Matrix
| Role | Access Rights |
|---|---|
| Admin | Create/Edit/Delete |
| Contributor | Create/Edit |
| Reviewer | Read/Edit Comments |
| Read-only | View only |
Annexure-2: Access Request Form
| Name | Role Requested | Justification | Approved By | Date |
|---|---|---|---|---|
| Meena Sharma | Contributor | CRA filing access | QA Manager | 05/09/2025 |
Annexure-3: Inspector Access Log
| Date | Inspector Name | Agency | Access Duration | Status |
|---|---|---|---|---|
| 15/09/2025 | John Smith | FDA | 3 days | Closed |
Annexure-4: Access Control Log
| Date | User | Action | Performed By |
|---|---|---|---|
| 12/09/2025 | Arjun Patel | Access Revoked | TMF Admin |
Annexure-5: Security Incident Log
| Date | Incident | Reported By | Action Taken | Status |
|---|---|---|---|---|
| 20/09/2025 | Failed login attempts | System Admin | Account locked | Resolved |
Revision History
| Revision Date | Revision No. | Revision Details | Reason for Revision | Approved By |
|---|---|---|---|---|
| 26/08/2025 | 00 | Initial version | New SOP creation | Head Clinical Quality |
For more SOPs visit: Pharma SOP