New UVA Researcher Information Form
INSTRUCTIONS AND INFORMATION
 Complete this form if you are coming to UVA and will be doing any of the following:
o Continue to work on a research protocol at your previous institution after you have transferred to UVA.
Protocol will not be opened at UVA.
o Transfer data /specimens to UVA from your previous institution
o Open a new protocol at UVA which is ongoing at your previous institution.
 Once completed email this form to the IRB-HSR office - irbhsr@virginia.edu.
 Once received you will receive an email from an IRB staff member to set up a time to discuss your plans for
research at UVA.
First Name:
Middle Initial:
Last Name:
Current Phone:
Current Email:
UVA Phone (if known) :
UVA Email (if known) :
UVa ID:
Name of Institution moving from:
Name of UVA School coming to:
Name of UVA Department coming to :
Additional contact ( if applicable)
Name:
1.
Phone:
Email:
Will you be maintaining an appointment at your previous institution?
If YES, when will your appointment at your previous institution end?
If YES, will you continue to work on any non-exempt research protocols at your
previous institution after you transfer to UVA?
If YES- complete Appendix A
2.
3
Do you plan to bring data or specimens with you to UVA?
If YES- complete Appendix B
If YES, were the data/specimens collected under a research consent form?
If YES, attach a copy of the consent form used to collect the data/specimens.
Will you be transferring a Grant Proposal to UVa?
If YES- see IRB-HSR Grant Submission Process for steps to follow to obtain IRB
approval of your Grant.
Submitted by:
Date:
Website: http://www.virginia.edu/vpr/irb/hsr/index.html
Phone: 434-924-2620 Fax: 434-924-2932 Box 800483
Version date: 05/16/16
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Yes
No
Yes
No
Yes
No
Yes
No
Appendix A:
Protocols you plan to continue working on at previous institution after transferring to UVA.
Protocol Title
Do you plan to
open this protocol
to enrollment at
UVA?
Is this protocol currently
overseen by a Central/Single
IRB?
If yes, list name of IRB of Record
Information for Submission Requirements:
All subjects enrolling only at previous institution and no data (Identifiable or Limited Data Set) will
come to UVa

Submit a Determination of Non- UVa Agent Form to the UVA IRB-HSR
Subjects will be enrolled at previous institution and UVA

Submit an IRB Reliance Agreement Request Form – Non- UVA IRB as IRB of
Record to the IRB-HSR for a Non- UVA IRB to serve as the IRB of Record
OR

Proceed to Protocol Builder to create a submission to the IRB-HSR for the IRB-HSR
to serve as the IRB of Record.
Transferring data/ specimens to UVA

If data/specimens are “Identifiable” per HIPAA regulations- proceed to Protocol
Builder to submit a database protocol reviewed by expedited review procedures
through the UVA IRB-HSR

Data/specimens meet the criteria of a Limited Data Set per HIPAA regulationsproceed to Protocol Builder to submit a need an exempt application through the
UVA IRB-HSR.
Website: http://www.virginia.edu/vpr/irb/hsr/index.html
Phone: 434-924-2620 Fax: 434-924-2932 Box 800483
Version date: 05/16/16
Page 2 of 4
Appendix B: HIPAA Identifiers
Check all HIPAA Identifiers below related to the data/specimens you are bringing to UVA that you
will have access to after you transfer to UVA.
Yes
No 1. Name
Yes
No 2. All geographic subdivisions smaller than a state, including street address, city, county,
precinct, zip code, and their equivalent geocodes, except for the initial three digits of the
zip code if, according to the current publicly available data from the Bureau of the Census:
(1) The geographic unit formed by combining all zip codes with the same 3 initial digits
contains more than 20,000 people and (2) The initial 3 digits of a zip code for all such
geographic units containing 20,000 is changed to 000.
Yes
No 3. All elements of dates (except year) for dates directly related to an individual, including
birth date, admission date, discharge date, date of death; and all ages over 89 and all
elements of dates (including year) indicative of such age, except that such ages and
elements may be aggregated into a single category of age 90 or older.
[This means you may record the year but not record the month or day of any date related
to the subject if the subject is under the age of 89. In addition if the subject is over the age
of 89 you may not record their age and you may not record the month, day or year of any
date related to the subject ]
Yes
No 4. Telephone numbers
Yes
No 5. Fax numbers
Yes
No 6. Electronic mail addresses
Yes
No 7. Social Security number
Yes
No 8. Medical Record number
Yes
No 9. Health plan beneficiary numbers
Yes
No 10. Account numbers
Yes
No 11. Certificate/license numbers
Yes
No 12. Vehicle identifiers and serial numbers, including license plate numbers
Yes
No 13. Device identifiers and serial numbers
Yes
No 14. Web Universal Resource Locators (URLs)
Yes
No 15. Internet Protocol (IP) address numbers
Yes
No 16. Biometric identifiers, including finger and voice prints
Yes
No 17. Full face photographic images and any comparable images
Yes
No 18. Any other unique identifying number, characteristic, code that is derived from or
related to information about the individual (e.g. initials, last 4 digits of Social Security #,
mother’s maiden name, first 3 letters of last name.)
Yes
No 19. Any other information that could be used alone or in combination with other
information to identify an individual. (e.g. rare disease, study team or company has access
to the health information and a HIPAA identifier or the key to the code . )
If you answered NO to all items above the data/specimens are considered to be non- identifiable.
Website: http://www.virginia.edu/vpr/irb/hsr/index.html
Phone: 434-924-2620 Fax: 434-924-2932 Box 800483
Version date: 05/16/16
Page 3 of 4
If you checked YES to any item in the table above, check YES to any HIPAA identifier below related
to the data/specimens you are bringing to UVA that you will have access to after you transfer to
UVA.
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1. Name
2. Postal address information, other than town or city, state, and zip code
3 Age if over the age of 89 OR Date of Birth if over the age of 89
4. Telephone numbers
5. Fax numbers
6. Electronic mail addresses
7. Social Security number
8. Medical Record number
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers and serial numbers, including license plate numbers
13. Device identifiers and serial numbers
14. Web Universal Resource Locators (URLs)
15. Internet Protocol (IP) address numbers
16. Biometric identifiers, including finger and voice prints
17. Full face photographic images and any comparable images
18. Any other unique identifying number, characteristic, code that is derived
from or related to information about the individual (e.g. initials, last 4
digits of Social Security #, mother’s maiden name, first 3 letters of last
name.)
19. Any other information that could be used alone or in combination with
other information to identify an individual. (e.g. rare disease, study team
or company has access to the health information and a HIPAA identifier or
the key to the code . )
If you checked NO to all items listed above and data/specimens are considered to meet the criteria of
a Limited Data Set.
Website: http://www.virginia.edu/vpr/irb/hsr/index.html
Phone: 434-924-2620 Fax: 434-924-2932 Box 800483
Version date: 05/16/16
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