| Certification for Activities Preparatory to Research Compliance with HIPAA Privacy Rule Requirements for Use of PHI. | |
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Certification of Completion of Human Subjects Protection Training Program and List of Personnel Who Will Use Protected Health Information (PHI). | |
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Certification for Research on the Protected Health Information of Decedents. | |
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Certification for Use of a Limited Data Set Within the UW Health Care Component or Within the UW Affiliated Covered Entity | |
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Data Use Agreement
for Disclosures of Limited Data Sets An agreement between a covered entity and a person or entity that receives a limited data set. |
|
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Responding
to a Data Use Agreement for use of a Limited Data Set by a UW Researcher. A checklist of the required elements of a Data Use Agreement. |
|
| Microsoft Excel document (.xls) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Database
Decision Tool Guidance for applying HIPAA Privacy Rule Requirements in creation and use of databases containing Protected Health Information. |
|
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Database Registration Form and Preparatory to Research Certification for Database Custodian. | |
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Disclosures Log A tool used to record all disclosures of research subjects' Protected Health Information. |
|
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Microsoft Excel document (.xls) | |
| Instructions for Research Authorization Form | |
| Microsoft Word document (.doc) | |
| PDF - Non Fillable | |
| Research
Authorization Form Authorization to Use and Disclose Protected Health Information Addendum to Research Subject Information and Consent Form. In order to fill this form out correctly, you may need to read the Instructions for Research Authorization Form. |
|
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Research Authorization
Form for Children Authorization to Use and Disclose a Child's Protected Health Information Addendum to Research Subject Information and Consent Form. In order to fill this form out correctly, you may need to read the Instructions for Research Authorization Form. |
|
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Combined HIPAA Research Authorization and Common Rule Informed Consent Form An interactive program for the development of a combined form that contains the required elements for authorization under HIPAA and informed consent under the Common Rule. |
|
| Go to the online form | |
| Instructions for Waiver of Authorization, Partial Waiver, or Altered Authorization | |
| Microsoft Word document (.doc) | |
| HTML Web Page | |
| Waiver of Authorization Application, Partial Waiver of Authorization, or Altered Authorization | |
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
Veteran's Administration (VA) HIPAA Research Forms
| Veteran Administration
(VA) Research Authorization Form Authorization to Use and Disclose PHI for research participants at the VA Hospital. |
|
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Veterans
Administration (VA) Addendum for Sponsor-Specific Language Addendum for addition of requested language to VA research authorization form. |
|
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Veterans Administration (VA) Preparatory to Research Certification Form | |
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
| Veterans Administration (VA) Waiver of Authorization Application Form |
|
| Microsoft Word document (.doc) | |
| PDF - Fillable | |
| PDF - Non Fillable | |
Return to HIPAA Research Guide main page
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Last updated: April 23, 2004