Accounting of Disclosures
Accounting of Disclosures Log: this log must be used to record all disclosures of research subjects’ protected health information which occur based on an IRB waiver of authorization.
Authorizations for Use or Disclosure of PHI in Research
Please note, these are templates only. As with your research consent form, your HIPAA authorization form will need to be tailored to fit the particular uses and disclosures of PHI in your study.
Research Authorization for Children
Research Authorization Wizard (not for interventional studies)
Combined Research Consent and Research Authorization Wizard (not for interventional studies)
Research Authorization — Veterans Affairs (VA)
Certification for Activities Preparatory to Research: this certification must be signed prior to using PHI in the preparation of a research protocol.
Certification for Research on the Protected Health Information of Decedents: this certification must be signed when the research, or a distinct part of the research, uses only the protected health information of decedents.
Certification for Disclosure of a Limited Data Set from the UW-Madison Health Care Component: this certification must be signed when a UW-Madison employee outside of the health care component receives a limited data set from within the health care component.
Certification for Use of a Limited Data Set Within the UW HCC or UW ACE: this certification must be signed when an employee within the health care component or within the affiliated covered entity receives a limited data from the the same.
Database Forms and Tools
Database Decision Tool: this tool is used to determine if a database that is used for research purposes must be registered with the UW-Madison HIPAA Privacy Officer.
Database Registration and Preparatory to Research Certification for Database Custodian: this form is used to register a database with the UW-Madison Privacy Officer and, when applicable, for the database custodian to certify use of the database in preparation of a research protocol.
Data Use Agreement and Related Forms
Data Use Agreement: This agreement must be completed before receiving or disclosing a Limited Data Set (“LDS”).
Data Use Agreement Evaluation Form: Use this form to evaluate another Covered Entity’s DUA when UW-Madison is the intended recipient of a LDS.