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Forms and Policies

IRB HIPAA-Related Forms

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IRB HIPAA-Related Forms

  •  HIPAA Authorization Form: Permission to Use, Create and Share Health Information for Research – revised April 11, 2013 (DOC)
    • Also available in the following languages:
    • The Word versions of the translated HIPAA forms are provided for the convenience of the study team. Like the English HIPAA forms, these translations should not be altered, except where allowed by the form itself. Study teams should use English to fill in any editable fields (any language other than English requires Certification of Translation).
    • If the study team needs to use the “other” field in the PHI section and/or if English is not used in other editable sections, then the form must be certified translated.
    • For the languages available on the website, study teams should use these certified translations because they contain English prompts.
    • This form is used in addition to the research study consent form. The form contains all the elements needed to be compliant with the federal privacy rule known as HIPAA.
  • Electronic Research Disclosure Tracking Form (for use within Children’s network)
  • Printable Research Disclosure Tracking Form (PDF) (for use outside Children’s network)
    • Use this form when a Children’s patient's health information (PHI) is accessed electronically (e.g., CIS, Invision, department databases) for use in an IRB-approved research study, where use of the information has not been authorized by the patient/parent (IRB approved a waiver of authorization) and when the research team contains members who are not part of Children’s workforce.
    • Employees of Children’s, CUMG, and residents and fellows working at Children’s are part of Children’s workforce.
    • Your data will be automatically fed into Children’s disclosure tracking system when you enter it into the electronic Research Disclosure Tracking Form. Children’s must track all disclosures of PHI that were made without an authorization.

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