Request for Research on Decedents' Information

Complete this form to submit a request to review decedents' information for research purposes.

The approval of this request is contingent upon the following conditions. Submitting the form indicates you agree to all of the following, and that you certify that you will carry out the proposed data collection in compliance with these principles. You also certify that the protected health information will not be reused or disclosed to any other person or entity, except as required by law, for authorized oversight of the research study, or for other permitted uses and disclosures according to federal regulations.