Supplemental Form: Protected Health Information (PHI) Submit this form in addition to the IRB Research Proposal in IRBAccess when a study involves the use of PHI. Study Number Type of Authorization Requested Select which types of authorizations or uses of protected health information requested. Obtaining participant authorization for access of PHI Upload Patient HIPAA Authorization Form or include required information in uploaded Informed Consent Waiver or alteration of HIPAA Partial waiver for subject authorization requirement identification or recruitment Complete Waiver or Alteration of Complete Waiver or Alteration of Authorization Request section below Authorization Request section below Health Information Use Request Covered entit(ies) providing the PHI: Types of Identifiers Recorded in the Study Select all identifiers associated with the PHI. Dates (including month/year) Names Admission, birth, death, or procedure date, ages over 89 Vehicle identifiers and serial Telephone numbers numbers, including license plate numbers Device identifiers and serial Facsimile numbers numbers Web universal resource locators Electronic mail addresses (URLs). Internet protocol (IP) address Social security numbers numbers. Biometric identifiers, including Medical record numbers fingerprints and voiceprints. Full-face photographic images and Health plan beneficiary numbers any comparable images. Account numbers Geographic subdivisions Describe geographic subdivisions Certificate/license numbers
Supplemental Form: Protected Health Information (PHI) Submit this form in addition to the IRB Research Proposal in IRBAccess when a study involves the use of PHI. Study Number Type of Authorization Requested Select which types of authorizations or uses of protected health information requested. Obtaining participant authorization for access of PHI Upload Patient HIPAA Authorization Form or include required information in uploaded Informed Consent Waiver or alteration of HIPAA authorization requirement Partial waiver for subject identification or recruitment Complete Waiver or Alteration of Authorization Request section below Complete Waiver or Alteration of Authorization Request section below Health Information Use Request Covered entit(ies) providing the PHI: Types of Identifiers Recorded in the Study Select all identifiers associated with the PHI. Names Dates (including month/year) Admission, birth, death, or procedure date, ages over 89 Telephone numbers Vehicle identifiers and serial numbers, including license plate numbers Facsimile numbers Device identifiers and serial numbers Electronic mail addresses Web universal resource locators (URLs). Social security numbers Internet protocol (IP) address numbers. Medical record numbers Biometric identifiers, including fingerprints and voiceprints. Health plan beneficiary numbers Full-face photographic images and any comparable images. Account numbers Geographic subdivisions Certificate/license numbers Describe geographic subdivisions
Supplemental-IRB-Application-PHI.docx