HIPAA Forms

These are standards forms and guidelines for HIPAA. DO NOT ALTER THE TEXT THAT IS EMBEDDED IN THESE DOCUMENTS. Simply insert at the designated spaces the responses to the information on the template. Once completed, Submit to the IRB office for approval.

• HIPAA Compliance Application (Word doc)
• Record, Chart Review, or Computer Database Research (Word doc)
• Request for Discarded/Stored Human Biological Specimens (Word doc)
• Application for Waiver of Authorization (PDF doc)
• PI Attestation - Research using Decedent Information (Word doc)
• Revocation Letter (PDF doc)
• Data use Agreement (PDF doc)

Consent Templates

Templates are all Word Documents.

• Elements of Consent (Word doc)


• Biomedical (Word doc)


• Behavioral (Word doc)


• Oncology NCI Consent (Word doc)


• Assent for Minors (Word doc)


• You/Your Child (Word doc)


• Bill of Rights (Word doc)


• Bill of Rights in Spanish (Word doc)


• HIV Wording (Word doc)

COI Form

The Research Institute Conflict of Interest policies regarding disclosures have not changed, so you are being asked to reveal any "financial interests which may compromise or have the appearance of compromising an investigator's professional judgment in conducting or reporting research". You must disclose your relevant financial interests as well as those of your spouse, your domestic partner or your dependent children.

COI Form (Word doc)


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