Forms
Data Use Committee Instructions
By routing a Project Request Form through upper management, institutional suitability can be assessed, as well as the type of support required. The DUC works in conjunction with, and on behalf of, the IRB on regulatory matters involving HIPAA and research.
Project Request Form
All research and non-research (Quality Improvement, Evidence Based Practice or Evaluation) projects that request the use of Cottage patient data are required to be reviewed by the DUC. If your project involves the use of Cottage patient or employee data, you will need to complete the Project Request Form. The information presented in the Project Request Form will be reviewed and evaluated by the DUC to confirm the scope of the project and to ensure that all HIPAA Privacy and Security regulations are in place prior any collection of data.
The Project Request Form will be routed through Cottage management so institutional suitability can be assessed, as well as the type of support required. The DUC works in conjunction with, and on behalf of, the IRB on regulatory matters involving HIPAA and research.
Download Project Request Form #001c
Case Report Request Form
Case reports/series involve the collection and presentation/dissemination of detailed information about a particular patient or a group of patients in order to highlight an interesting condition, treatment, presentation or outcome.
If your case report/series involves the use of Cottage patient data, you will need to complete the Case Report Request Form. The DUC does need to review the request prior to the individual obtaining the data, in order to ensure that no other HIPAA or institutional/operational considerations are required. While HIPAA authorization from the patient(s) may not always be required, there may be instances in which individual authorization from the patient may be needed to use their health information. The DUC will assist you in making this determination. Regulations require that IRB review and approval will also be necessary if your case series includes 3 or more patients.
Download Case Report Form #400
001a - DUC Application ALL Resident QI Projects
This document is similar to the Project Request Form (#001c) but specifically focuses on a QI project application.
Download DUC Application ALL Resident IQ Projects Form #001a
Comparing and Contrasting Types of Projects
This is a reference document that describes the qualities of different project types. This will assist researchers in their project applications.
Download Comparing and Contrasting Types of Projects Form
701 - IRB Cover Page
This form should accompany all submissions to the IRB. It is a summary that provides a high-level overview of the study details (e.g., personnel, contact information, purpose of protocol, population studied, nature of IRB submission).
Download IRB Cover Page Form #701
707b - Waiver or Altered Authorization Request
This form facilitates the submission and review of a request to use/disclose protected health information (PHI) under an IRB approved Waiver of or Altered Authorization. This application must be completed to use/disclose PHI located either in a medical record or in a database.
Download Waiver or Altered Authorization Request Form #707b
