Request to access PHI-preparatory for research
This request is to be submitted if you intend to view subject’s Protected Health
Information (PHI: any information that might identify someone either directly or
indirectly) before submitting a protocol to the IRB. This service can not be used to share
information with any party outside the American University of Beirut prior to submitting
a protocol. Kindly submit a full protocol to the IRB once you have enough information to
support conduction of your proposed research.
1.
Name of the Person who will access PHI: ------------------------------Email address: ----------------------------Phone number: ----------------------------CITI Training: Yes
2.
No
Name of the Principal Investigator: ------------------------------Email address: ------------------------------Phone number: ------------------------------CITI Training: Yes
3.
No
Please specify the type of PHI (medical records, imaging studies, pathology information,
lab information, etc..): -------------------------------
4.
I hereby certify all the following:




The use of PHI is only to prepare a research protocol.
The work will not involve recording or removing PHI from the American University of Beirut
or the American University of Beirut Medical Center.
The requested PHI is necessary for the purposes of the research
I will protect the confidentiality and security of this information while in my possession.
Signature of the Person who will access PHI: --------------------------Signature of the Principal Investigator: ---------------------------------Date of the request: --------------------------------------------------
Reviewed and approved by the IRB Chair/Vice Chair: ---------------------Date of access approval: ----------------------------------------------------------
V1. September 7, 2011