Version 3.0
Research Integrity Office
Mail code L106-RI
3181 S.W. Sam Jackson Park Road
Portland, Oregon 97239-3098 tel: 503 494-7887 | fax: 503 494-5081
This form must be completed by the Principal Investigator who intends to examine Protected Health
Information (PHI) of deceased persons.
1. Check one:
IRB Submission #
Not associated with an IRB submission
This form must be completed before the investigator(s) accesses those records/specimens.
2. Principal Investigator (PI) Name:
3. The PI listed in #2 above and other investigators/research staff associated with this project intend to examine records/specimens for the following research purposes: (please describe)
4. Please identify the source (e.g., tissue specimens, database, medical records) of the records/specimens of deceased persons the investigator(s) proposes to examine for this research:
5. Will the PHI be shared with anyone outside of OHSU?*
Yes No
If YES, what PHI will be shared and how will it be identified? (name of decedent, coded identifiers, etc.)
In submitting this form, the investigator represents and agrees to the following:
A. The use or disclosure of PHI is sought solely for research on the PHI of decedents.
B. The PHI is necessary for the research purposes.
C. If the Institutional Review Board requests it, the investigator(s) will provide documentation as to the death of the individuals.
*Note: You are required to comply with the OHSU policy for accounting of disclosures of PHI as it applies to the use and/or disclosure of PHI described in this form.
If submitted via the eIRB, this request is approved upon receipt of an IRB approval or determination memo. If not associated with an eIRB submission, the request is approved upon signature of the
IRB Chair or designee below.
ORIO OFFICE USE ONLY (if applicable)
Chair Signature:
Date
Last Revised: 3.5.2014 Page 1 of 1