ࡱ> :N9O ~bjbj;; .lQWilQWiV '""8?8(````;;;$vj;;jj``jv``j`W@0?   ;>y,$;;;|;;;?jjjj ;;;;;;;;;"X z: HIPAA-IRB Form 5: Submit to the IRB Office (Revised June 2010) REPRESENTATIONS FORM FOR RESEARCH INVOLVING ONLY DECEDENTS INFORMATION The Privacy Regulations issued under the Health Insurance Portability and Accountability Act (HIPAA) require researchers to make certain representations before using or disclosing decedents protected health information (PHI) for research. A use is sharing PHI among the Hopkins workforce. A disclosure is sharing PHI with someone outside the Hopkins workforce. This form must be completed by the researcher who intends to examine records/specimens of deceased persons that contain PHI before the researcher examines those records. NOTE: The researcher must track disclosures of PHI which are made in the course of the review of decedents PHI. This means that a record of any disclosures made during the review must be kept. The form may be found at either  HYPERLINK "http://www.insidehopkinsmedicine.org/hipaa/policytemplates.cfm%23providers" http://www.insidehopkinsmedicine.org/hipaa/policytemplates.cfm#providers as form A.13.2.e., or at  HYPERLINK "http://irb.jhmi.edu/HIPAA/HIPAA_Forms/index.html" http://irb.jhmi.edu/HIPAA/HIPAA_Forms/index.html as HIPAA SOM IRB Form 5. The researcher intends to examine records/specimens of deceased persons for the following research purposes: (please describe) Please identify the source (e.g., specimen bank, database, medical record, EPR, etc.) of the records/specimens of deceased persons the researcher proposes to examine for this research: The researcher makes the following representations: 1. The use or disclosure of PHI is sought solely for research on the PHI of decedents. 2. If the Institutional Review Board requests it, the researcher will provide documentation as to the death of the individuals. 3. The PHI is necessary for the research purposes. _________________________________________________ _______________________ Signature of Researcher Date Faculty Title, if any _____________________________________ Job Title, if not faculty ___________________________________ Organization for faculty or non-faculty ______________________________ _____________________________________________________________________________________________ Print Name     Effec. 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