HIPAA Forms

If you are a Main Campus and/or social behavioral science researcher, please use the templates on the Main Campus page.

All IRB applications must be submitted using the ERICA system. Templates that can be attached with your ERICA application are listed below.

Who is in the Covered Entity?

Forms	Version Date
Advertisement Guidelines	07.23.2008
Assent Template	12.19.2006
Case Report Using Existing Data Author Worksheet	06.01.2007
CCIC New Submission Information Sheet	01.11.2008
Certification for Emergency Use of a Test Article without Informed Consent	03.10.2008
Consent Template	04.23.2008
Data Use Agreement - UUHSC	07.23.2008
Data Use Agreement - IHC	06.09.2008
HIPAA Assurance Letter Template	12.28.2007
HUD Assent Template	03.17.2008
HUD Consent Template	04.23.2008
HUD Parental Permission Template	03.17.2008
HUD VA Consent Template	04.23.2008
Information for Accounting of Disclosures	12.28.2007
IRB Authorization Agreement (IAA)	07.21.2008
Parental Permission Template	04.27.2007
Protocol Summary	12.19.2006
Quarterly Report
Questionnaire Cover Letter - Instructions for Use
Questionnaire Cover Letter Template	08.28.2007
Research Compliance Agreement - Individual Investigator	07.21.2008
Research Compliance Agreement - Institution	07.21.2008
Research Preparation Checklist	04.06.2007
Research-Related Injury Statements - Spanish	12.12.2007
Research Using Decedents Info	06.09.2005
Short Form Consent - Instructions for Use	05.22.2007
Short Form Consent Template (English)	04.27.2007
Short Form Consent Template (Spanish)	04.27.2007
Spanish Short Form Translation Certificate	02.13.2008
Sponsor - Investigator Policies and Procedures Templates - Devices	04.11.2008
Sponsor - Investigator Policies and Procedures Template - Drugs and Biologics	04.11.2008
Tissue Bank Consent Language
Translation Certification Letter
VA Consent Template	04.23.2008
VA Form 10 1223	10.1995
VA Preparation Research Form	04.06.2007