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HIPAA Forms

		HIPAA Research Forms	Version Date
1.		Authorization for Use and Disclosure of Health Information for Research	05/2008
	1.1	HIPAA Authorization for International Research	06/2009
2.		Combined Informed Consent/Authorization Template All new and revised consent forms are required to be on this template as of April 1, 2010. Consent forms received after April 1, 2010 on an outdated template will be returned and the application will not be processed until the correct consent forms are submitted.	01/2010
3.		Authorization to Contact You About Future Research Studies	02/2009
4.		Application for IRB Waiver of HIPAA Privacy Authorization	02/2009
5.		Representations Form for Research Involving Only Decedents' Information	03/2004
6.		Representations Form for Reviews Preparatory to Research	03/2004
7.		HIPAA IRB Form 7 series are no longer in use.
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	10/2004
	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	10/2004
	8.3	Tracking Form - Research Involving Disclosures About 50 or More Individuals	10/2004
	8.4	Tracking Form for Permitted General Disclosures of PHI from Clinical or Research Records	01/2007
9.		Data Use Agreement (Revised)	12/10/09
10.		Use or Disclosure of Psychotherapy Notes for Research	03/2004
	10.1	Authorization for Use or Disclosure of Psychotherapy Notes for Research (and instructions)	03/2004
11.		Confidentiality Agreements
	11.1	Confidentiality Agreement for Medical Staff, Resident Staff and Other Credentialed Staff Members	03/2004
	11.2	Confidentiality Agreement for Workforce Members-General	08/2004
	11.3	Confidentiality Agreement for Professional Staff and other Credentialed Practitioners - Howard County General Hospital	11/2004

If you have any comments, questions or suggestions
you may contact the JHM IRB at:

p: 410.955.3008 | f: 410.955.4367 or 443.287.5353 | e: jhmirb@jhmi.edu