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Institutional Review Board

HIPAA Forms

 HIPAA Forms
 Authorization Forms
1. Authorization for Use and Disclosure of Health Information for Research 
1.1 HIPAA Statement for International Research Form

2. Combined Informed Consent/Authorization Template

3. Authorization to Contact You About Future Research Studies: Adult
    Authorization to Contact You About Future Research Studies: Child

4. Application for IRB Waiver of HIPAA Privacy Authorization

5. Representations Form for Research Involving Only Decedents' Information

8.  Tracking Forms for Research Associated Disclosures

8.1 Tracking Form for Disclosure of PHI from Research Records
      For Disclosures as Part of the Research Process - Basic Form
 8.2 Tracking Form for Disclosure of PHI from Research Records
       For Multiple Disclosures about an Individual to the Same Person or Entity for Single Purpose as Part of the Research Process
 8.4 Tracking Form for Permitted General Disclosures of PHI from Clinical or Research Records
 9. If you require a Data Use Agreement please contact ORA  or JHURA [email protected]
 10. Use or Disclosure of Psychotherapy Notes for Research
 10.1 Authorization for Use or Disclosure of Psychotherapy Notes for Research (and instructions)

11. Confidentiality Agreements
 11.1 Confidentiality Agreement for Medical Staff, Resident Staff and Other Credentialed Staff Members
 11.2 Confidentiality Agreement for Workforce Members-General
12. Authorizations
 12.1 Authorization for Use of Research Information and Photographs