Resource Contacts Privacy Officer (PO) Name VA E-Mail Address Phone Number Rita Davison / Virginia Rhodes (919) 384-8582 x 4022 (919) 286-0411 x5981 Information Security Officer (ISO) Name VA E-Mail Address Number Gardiner / Michelle Denison (919) 286-0411 x 5793 / x 6420 Research Compliance Officer (RCO) Name VA E-Mail Address Phone Number Margaret Jones / Kathy Jeter / (919) 286-0411 x 7616 / x 7658 Records Management Officer (RMO) Name VA E-Mail Address Phone Number Katherine Carter (919) 286-0411 x 6194 Study Information Principal Investigator (PI) Name VA E-Mail Address Number Title Protocol Number (if available) Contact Name VA E-Mail Address Phone Number Check all of the following that apply to this submission: Purpose of Submission: New Protocol Continuing Review Amendment Only change is adding study personnel. If so, answer questions 1 & 26 & proceed to PI Signature Section Only change is study personnel have been removed from the study. If so, answer question 41 and proceed to Signature Section Change in data collection/use/storage/transmission/disposition Change in HIPAA Authorization Change in VA Informed Consent Change in Data Use Agreement Enrollment Status: Open Closed Funding Source: None VA/Coop NIH or Other Government Agency Private Funding. Specify: Data Use Information: Written Agreements Regarding Data Use Data Use Agreement exists Videos, pictures or audio recordings will be obtained Study will require a contractor who will have access to VA sensitive data. Specify contractor and services:
Resource Contacts Privacy Officer (PO) Name Rita Davison / Virginia Rhodes VA E-Mail Address Phone Number (919) 384-8582 x 4022 (919) 286-0411 x5981 Information Security Officer (ISO) Name Gardiner / Michelle Denison VA E-Mail Address Number (919) 286-0411 x 5793 / x 6420 Research Compliance Officer (RCO) Name Margaret Jones / Kathy Jeter VA E-Mail Address / Phone Number (919) 286-0411 x 7616 / x 7658 Records Management Officer (RMO) Name Katherine Carter VA E-Mail Address Phone Number (919) 286-0411 x 6194 Study Information Principal Investigator (PI) Name VA E-Mail Address Number Title Protocol Number (if available) Contact Name VA E-Mail Address Phone Number Check all of the following that apply to this submission: Purpose of Submission: New Protocol Continuing Review Amendment Only change is adding study personnel. If so, answer questions 1 & 26 & proceed to PI Signature Section Only change is study personnel have been removed from the study. If so, answer question 41 and proceed to Signature Section Change in data collection/use/storage/transmission/disposition Change in HIPAA Authorization Change in VA Informed Consent Change in Data Use Agreement Enrollment Status: Open Closed Funding Source: None VA/Coop NIH or Other Government Agency Private Funding. Specify: Data Use Information: Written Agreements Regarding Data Use Data Use Agreement exists Videos, pictures or audio recordings will be obtained Study will require a contractor who will have access to VA sensitive data. Specify contractor and services:
Checklist_for_Reviewing_Privacy_Confidentiality_and_Information_Security_2017_06.docx