Springfield Committee for Research Involving Human Subjects
Southern Illinois University School of Medicine  Memorial Medical Center  St. John’s Hospital
801 North Rutledge Street  P.O. Box 19616  Springfield, Illinois 62794-9616
Telephone: (217)545-2172  Fax: (217) 545-7873
Researcher Representation for Research on Decedents
[Insert name of Principal Investigator] ("PI") has requested permission of [Insert name of practice] to
use certain decedent information maintained by [Insert name of practice] to [Insert description of the
purposes of the PI's use of the information].
The information to be used by the PI includes:
[Provide a description of the type of patient information that the PI will be using.]
PI will use the above described patient information from [Insert the dates that the PI will be examining
the information].
PI represents to [Insert name of practice] that all of the following are true and accurate:
1. The use sought is solely for research on the protected health information of decedents;
2. The patient health information for which use is sought is necessary for the research purposes.
PI must provide documentation confirming the death of each individual whose health information will be
accessed and used by researcher.
SCRIHS reserves the right to terminate PI's use of the requested information at any time that SCRIHS has
reason to believe that the PI has violated any of the conditions set forth in paragraphs 1 to 2 above or has
accessed any information not described herein for any purpose not described herein.
_____________________________________________________________________________________
Principal Investigator
Date
This request has been reviewed and approved by the Springfield Committee for Research Involving
Human Subjects.
_____________________________________________________________________________________
Chairman or Acting Chairman
Date
Springfield Committee for Research Involving Human Subjects