Review Preparatory to Research
Complete this form if protected health information of individuals who are not under the care of the investigators may be reviewed before participants authorize this access.
Principal Investigator First Name
Principal Investigator Last Name
Email of Principal Investigator or Appropriate Contact
Provide a brief description of why pre-review has to be done prior to the participants' authorization.
Investigators are required to only obtain the minimum necessary data in order to achieve the goals of the review. Provide a list of the information you intend to use.
Explain why the data you are obtaining are the minimum necessary to achieve the goals of the research.
Provide a description of the pre-review and your plan for prescreening the information.
The approval of this request is contingent upon the following conditions. Submitting the form indicates you agree to all of the following.
I agree that:
The use or disclosure is sought solely to review protected health information as necessary to prepare a research study or to determine eligibility or for similar purposes preparatory to research.
No protected health information will be removed from the covered entity by the research in the course of the review.
Use pf or access to the protected health information is necessary for the research purposes.
The use of the protected health information is in accord with the "Minimum Necessary" standard per federal requirements. The Minimum Necessary standard is the information reasonably necessary to accomplish the purpose of the rought or requested use or disclosure.
The research team members will sign the institution's Confidentiality Agreement.
Access to the information will be limited, to the greatest extent possible, within the research team.
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