Review Preparatory to Research Form Research Study Title: _________________________________________________________________ PI Name: __________________________________________ Representations by the researcher: (A) Use or disclosure is sought solely to review protected health information as necessary to prepare a research protocol or for similar purposes preparatory to research; (B) No protected health information is to be removed from the covered entity by the researcher in the course of the review; and (C) The protected health information for which use or access is sought is necessary for the research purposes. PI Signature: _______________________________________ Date: _____________________________________________
Review Preparatory to Research Form Research Study Title: _________________________________________________________________ PI Name: __________________________________________ Representations by the researcher: (A) Use or disclosure is sought solely to review protected health information as necessary to prepare a research protocol or for similar purposes preparatory to research; (B) No protected health information is to be removed from the covered entity by the researcher in the course of the review; and (C) The protected health information for which use or access is sought is necessary for the research purposes. PI Signature: _______________________________________ Date: _____________________________________________