HIPAA-related IRB Forms & Templates

Authorization Form Template

Customize this template and use in conjunction with a consent form during the consent process with potential subjects. It must be signed and dated by the subject or the subject's authorized representative as a consent for would be. Use and disclosures of PHI must be described in this document to receive IRB approval.

Please submit your customized authorization form for IRB approval along with your IRB application.

Authorization Form Template

Authorization Form Template for Recruitment Databases

Complete and submit this form to the IRB with an application to establish a recruitment registry assuring the IRB that data used in your research is authorized.

Authorization Form Template for Recruitment

De-Identification Certification Form

Complete and submit this form to the IRB to assure the IRB that data used in your research is de-identified. (see When is data "de-identified"?)

This form is required when applying for an Exemption of IRB Review for studies that will use de-identified data. This form is to be used in conjunction with the IRB's Exempt Screening Application form.

De-Identification Certification Form

Data-Use Agreement Template

Customize this template as an agreement that will be signed by the researcher as an agreement for how they will use/disclose the PHI provided to them by a covered entity.

Data-Use Agreement Template

Authorization Form to Establish a Database for Future Research

Customize this template and use in conjunction with a consent form during the consent process with potential subjects. It must be signed and dated by the subject or the subject's authorized representative as a consent form would be. Use and disclosures of PHI must be described in this document to receive IRB approval.

Please submit your customized authorization form for IRB approval along with your IRB application.

Authorization Form to Establish a Database for Future Research Template