ࡱ>  fbjbjVV 4r<<MAl l   eeeyyy85y .'-)-)-)-)-)-)-$/2dM-ey@"M-- p88'- '- VG*@M +yKd* --0 .*x3D3 +3e + M-M- .3l u: Appendix D: Request for Waiver of Authorization for Use or Disclosure of Identifiable Records or Protected Health Information (PHI) Project Title:  FORMTEXT       Note: The Illinois Department of Public Health (IDPH) Institutional Review Board (IRB) may grant a waiver(s) of authorization for disclosure or use of identifiable records or PHI if specified conditions are met. Complete the following for each proposed use or disclosure of identifiable records or protected health information. Do not sign this Appendix unless instructed to do so by the IDPH Responsible Individual. List on Application Coversheet. Use protocol-specific language to explain, and then sign the assurance below. The research must meet all the criteria below for a waiver of authorization. Please refer to the Waiver of Authorization on the following page before completing this section. Briefly describe the identifiable personal records or protected health information for which the waiver is requested1:1. The research involves no more than minimal risk to subjects. Explain:  FORMTEXT      2. The waiver of authorization will not adversely affect the rights and welfare of the subjects participating in the research. Explain:  FORMTEXT      3. It is not practical to obtain signed authorization for this disclosure. Explain:  FORMTEXT      4. It is not possible to conduct this research without use or disclosure of identifiable records or PHI. Explain  FORMTEXT      5. Identifiable information used or disclosed for this research will be protected from improper uses or disclosure. Explain:  FORMTEXT      6. This research is of sufficient importance to outweigh the intrusion into the privacy of subjects that will result from the use or disclosure of his/her identifiable records and/or protected health information. Explain:  FORMTEXT      7. When appropriate, the subjects will be provided with additional pertinent information after participation. Explain:  FORMTEXT      8. Explain when and how identifiable information used or disclosed for this research will be destroyed.  FORMTEXT      If you are requesting a waiver of authorization, provide your signed assurance: I assure that the Data Use Agreement for all identifiable personal records and/or protected health information that are used or disclosed for this research will be in place prior to data release; the Data Use Agreement will specify that the data will not be reused for other purposes, or disclosed to any other person or entity, except as specifically required or permitted by law and approved by the IDPH IRB; and that the Data Use Agreement will specify that no individual whose personal records or protected health information is used in this research will be identified in any written report resulting from this research. IDPH RESPONSIBLE INDIVIDUAL  FORMTEXT        FORMTEXT       Signature Date Waiver of Authorization Signed authorization for disclosure of personally identifiable records is required, unless the IDPH IRB approves a waiver. This is the case even if direct identifiers (name, Social Security Number, case numbers, medical record numbers, etc.) are not requested. A research protocol involves human subjects when personally identifiable information about individuals is used and disclosed for research purposes. Researchers should consider the following points when preparing the justification for a waiver of authorization. Criterion 1: The research involves no more than minimal risk to subjects. Every research project could potentially incur some risk to subjects. Explain the potential risk(s) to subjects specific to the proposed research. Explain why research risks are minimal. Explain procedures to lessen the possibility that the risk(s) would occur. Criterion 2: The waiver of authorization will not adversely affect the rights and welfare of the subjects participating in the research. Individuals have an inherent right to privacy of personally identifiable information. Research involving disclosure of records without authorization is, by its nature, intruding on subject privacy. Explain protections to ensure that the research, although an invasion of privacy, will minimize potential harms to subjects (physical, social, emotional, etc.). Criterion 3: It is not practical to obtain written authorization for this disclosure. Explain why it is not feasible, or could be detrimental to the research, to request a signed authorization from study subjects. Cost by itself is not sufficient justification. Criterion 4: It is not possible to conduct this research without use or disclosure of identifiable records or PHI. Explain why the specific identifiable records are necessary in order to conduct the research. Why couldnt the study be carried out with de-identified records? Are identifiers--even indirect identifiers--really necessary? Criterion 5: Identifiable information used or disclosed for this research will be protected from improper use or disclosure. Explain confidentiality protections for records disclosed for the research: who will have access, where records will be housed, when identifiers will be removed, security procedures for research offices, computers, local area networks (LANs) or networks, etc. Criterion 6: This research is of sufficient importance to outweigh the intrusion into the privacy of subjects that will result from the disclosure of his/her identifiable records and/or protected health information. Provide a strong scientific rationale for conducting the research. What would this research contribute to scientific knowledge or alleviation of a social/public health problem? In what ways would the importance of research findings justify intrusion into subject privacy? Criterion 7: When appropriate, the subjects will be provided with additional pertinent information after participation. Explain whether subjects will be given information about research findings and told that their records were disclosed for the research without their authorization. If subjects will not be contacted for this purpose, simply state this and explain why. 6    * ʶפteYL8'hh 5CJOJPJQJ^JaJh 5OJPJQJ^Jhaj9OJPJQJ^Jhaj95OJPJQJ\^J"hhaj95OJPJQJ\^Jh~L5OJPJQJ\^Jh ]5OJPJQJ\^J"hdhaj95OJPJQJ\^J'h]}h ]5CJOJPJQJ^JaJh ]5OJPJQJ^Jhdhaj95OJPJQJ^J0jhEhEOJPJQJU^JmHnHu  . V s$-DIfM gd>weK$ V$IfgdK$ V$Ifgd ]$ V&Zx$If^Za$gd ]$ V&Z$If^Za$gd ] V&Z$If^Zgd$ V&Z$If^Za$gdaj9* . 0 D F H R T X Z \ f h j    1 ? e o ߴ陸{ooo`o``T`Dh[4.h5OJPJQJ^Jh6OJPJQJ^JhhOJPJQJ^Jh)#OJPJQJ^Jh,OJPJQJ^JhOJPJQJ^J'h]}h]}5CJOJPJQJ^JaJh 5OJPJQJ^Jjh>weB*Uph$jhh B*Uphhh B*phjhh B*Uphhh 5OJPJQJ^JV X Z \ s r s {pg^ $Ifgd` $Ifgd~L $Ifgd~L Vx$Ifgd? 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If a waiver of authorization is approved by the IDPH IRB, state law requires that the records disclosed be de-identified when the research is completed. We generally expect that the de-identification standards in the HIPAA Privacy Rule be followed for this purpose. If an alternate method is proposed, explain it. State when identifiersincluding indirect identifierswill be permanently destroyed, and explain the mechanism for destruction. This includes, but is not limited to the destruction of paper printouts, disks, cleaning computer drives. Identifiable data includes (1) names; (2) all geographic subdivisions smaller than a state, except for the initial three digits of the ZIP code if the geographic unit formed by combining all ZIP codes with the same three initial digits contains more than 20,000 people; (3) all elements of dates except year, and all ages older than 89 or elements indicative of such age; (4) telephone numbers; (5) fax numbers; (6) email addresses; (7) social security numbers; (8) medical record numbers; (9) health plan beneficiary numbers; (10) account numbers; (11) certificate or license numbers; (12) vehicle identifiers and license plate numbers; (13) device identifiers and serial numbers; (14) URLs; (15) IP addresses; (16) biometric identifiers; (17) full-face photographs and any comparable images; (18) any other unique, identifying characteristic or code, except as permitted for re-identification in the Privacy Rule.      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