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Health Sciences Forms & Templates

Templates and forms on this menu have been designed to include elements required for biomedical studies, clinical trials, and other studies that include the use of protected health information (PHI).

Documents are in Word [DOC] format unless otherwise noted.

 

Consent Documents, Consent Cover Letters, Consent Information Sheets, Consent Scripts, etc.
FORMS Tracked Changes Version Date
Consent and Authorization Document Template Tracked Changes 11.13.2015
Consent and Authorization Document (for Minimal Risk Research) Template Tracked Changes 09.28.2015
Consent and Authorization Cover Letter Document Template Tracked Changes 10.25.2013
Consent Cover Letter Document Template Tracked Changes 11.20.2011
Pregnancy Follow-Up Consent and Release of Information Authorization Document Template Tracked Changes 10.25.2013
CCTS Consent Executive Summary Template (CCTS Document) Tracked Changes 01.03.2014
Tissue/Specimen Banking Consent Language Tracked Changes 09.15.2013
Witness Signature Page Tracked Changes 11.20.2011
Utah Population Database (UPDB) Consent and Authorization Requirements [PDF]   02.01.2011
Humanitarian Use Device (HUD) Consent and Authorization Document Template Tracked Changes 01.24.2014
Emergency Use Consent and Authorization Document Template   01.06.2015
IRB Guidance: Consent Process Models  N/A  
Parental Permission Documents
FORMS Tracked Changes Version Date
Parental Permission and Authorization Document Template Tracked Changes 11.13.2015
Parental Permission and Authorization Document (for Minimal Risk Research) Template Tracked Changes 09.28.2015
Humanitarian Use Device (HUD) Parental Permission and Authorization Document Template Tracked Changes 01.24.2014
Emergency Use Parental Permission and Authorization Document Template   01.06.2015
IRB Guidance: Consent Process Models  N/A  
Assent Documents
FORMS Tracked Changes Version Date
Assent Document Template Tracked Changes 02.08.2012
Humanitarian Use Device (HUD) Assent Document Template Tracked Changes 05.01.2014
IRB Guidance: Consent Process Models  N/A  
VA Documents and Forms (Consent Templates, Privacy and Information Security Forms, etc.)
FORMS Tracked Changes Version Date

VA Authorization for Use & Release of Health Information Form 10-0493

(Note: Some users have reported difficulties viewing this document via an internet browser.  Try downloading it/saving it to your desktop if you cannot view it online.)

N/A Sept 2015
VA Consent Document Template Tracked Changes 09.28.2015
VA Consent Cover Letter Template Tracked Changes 06.29.2015
VA Checklist for Reviewing Privacy, Confidentiality, and Information Security in Research   12.01.2010
VA Emergency Use Consent Document Template   08.17.2015
VA Financial Conflict of Interest Statement   11.2013
VA Humanitarian Use Device (HUD) Consent and Authorization Document Template Tracked Changes 08.17.2015
VA IRB Documentation of Waiver of HIPAA Authorization for Research [PDF]   07.2011
VA Revocation of Authorization for Use & Release of Health Information Form 10-10116 N/A Sept 2015
IRB Guidance: Consent Process Models N/A  
Translated Consent Documents
Translated Consent Documents
 FORMS  Tracked Changes  Translation Certificate Document Version Date Translated from English Version Date
Arabic Short Form Consent Document Template  

Short Form Translation Certificate (Arabic) [PDF]

ARCHIVED: Version K1310 [PDF]

L2815

G2012

 

Bosnian Short Form Consent Document Template   Short Form Translation Certificate (Bosnian) [PDF] 122010

12.20.2010

Burmese Short Form Consent Document Template**   Short Form Translation Certificate (Burmese) [PDF]- Redacted (for unredacted version, please contact the IRB) 12.14.2016

G2012 (072012)

Chinese-Cantonese Short Form Consent Document Template   Short Form Translation Certificate (Chinese-Cantonese) [PDF] 122010

12.20.2010

English Short Form Consent Document Template Tracked Changes  N/A

07.20.2012

(G2012)

 N/A

ARCHIVED: English Short Form Consent Document Template N/A N/A

04.27.2007,

K1310, L2010

N/A

English Short Form Parental Permission Document Template Tracked Changes  N/A

11.20.2013

(K2013)

N/A

ARCHIVED: English Short Form Parental Permission Document Template N/A N/A

07202012, 

122010, K1310

N/A

French Short Form Consent Document Template   Short Form Translation Certificate (French) [PDF]

C2012

12.20.2010
Korean Short Form Consent Document Template   Short Form Translation Certificate (Korean) [PDF]

11.19.2015

(K1915)

11.10.2015
Mandarin Chinese Short Form Consent Document Template  

Mandarin Chinese Translation Certification [PDF] - Redacted (for unredacted version, please contact the IRB)

04.08.2016

(D0816)

07.20.2012

(G2012)

Nepali Short Form Consent Document Template   Short Form Translation Certificate (Nepali) [PDF] 122010 12.20.2010
Russian Short Form Consent Document Template  

Russian Short Form Translation Certificate [PDF]

ARCHIVED: Version 04.27.2007 [PDF] 

04.25.2016

(D2516)

07.20.2012

(G2012)

Spanish Short Form Consent Document Template Tracked Changes

Short Form Translation Certificate (Spanish) [PDF]

ARCHIVED: Version 03.04.2015 [PDF]

ARCHIVED: Version 072012 [PDF]

ARCHIVED: Version 04.27.2007 [PDF]

C0415

07.20.2012

(G2012)

Spanish Short Form Parental Permission Document Template Tracked Changes Short Form Translation Certificate (Spanish) [PDF] K2013  K2013
Swahili Short Form Consent Document Template   Short Form Translation Certificate (Swahili) [PDF] (send request via email) 072012 07.20.2012
Thai Short Form Consent Document Template   Short Form Translation Certificate (Thai) [PDF] 072012 07.20.2012
Thai Short Form Parental Permission Document Template   Short Form Translation Certificate (Thai) [PDF] 072012 07.20.2012
Tongan Short Form Consent Document Template   Short Form Translation Certificate (Tongan) [PDF] 122010 12.20.2010
Vietnamese Short Form Consent Document Template   Short Form Translation Certificate (Vietnamese) [PDF] 072012 07.20.2012
Vietnamese Short Form Parental Permission Document   Short Form Parental Permission Translation Certificate (Vietnamese) [PDF] 072012 07.20.2012
Spanish Translations of IRB Consent Template Boilerplate Tracked Changes   03.08.2011  
Translation Certification Letter Template Tracked Changes   09.30.2015  
Witness Signature Block for Long Form     06.12.2012  
IRB Guidance: Consent Process Models  N/A   N/A  

 **MS Word may not display this document correctly.  If you have the required translation software, you can correct this issue by going to "Review > Language" and selecting the desired language.  If you have difficulty working with this document, please contact a member of the IRB Staff to assist you.

 

Recruitment Materials, Advertisements, etc.
FORMS Tracked Changes Version Date
Recruitment Letter Template   05.14.2010
Simple Referral Template   05.14.2010
Full Protocol Documents
FORMS Tracked Changes Version Date
Sponsor-Investigator Policies and Procedures Template - Devices Tracked Changes 01.03.2012
Sponsor-Investigator Policies and Procedures Template - Drugs and Biologics Tracked Changes 01.03.2012

External Sites and Agreements Documents
FORMS Tracked Changes Version Date
Data Use Agreement (DUA) Template - UUHSC - Please contactTechnology & Venture Commercialization (TVC)   N/A
Data Use Agreement (DUA) Template - IHC   06.09.2008
De-Identified Data/Specimen Sharing Agreement   08.21.2014
Information for Accounting of Disclosures Template   11.20.2011
Material Transfer Agreement (MTA) Template- Please contactTechnology & Venture Commercialization (TVC)   N/A
Reliance Agreement (RA) Template Tracked Changes

07.08.2016

(G0816)

Reliance Agreement for Unaffiliated Home Health Nurses Engaged in Research  

07.08.16

(G0816)

School Principal & District Permission Letter Template   10.08.2012
Other Documents
FORMS Tracked Changes Version Date
Certification for Emergency Use of a Test Article without Informed Consent   01.03.2012
Case Report Using Existing Data Author Worksheet [PDF] Tracked Version 09.01.2015
Department of Defense Supplement    08.19.2014
Exemption Umbrella Annual Report Template   09.01.2013
Expired Study Continuation Request Form   01.03.2012
Payment Process Exception Request Form   01.03.2012
Quarterly Report Template Tracked Version 01.03.2012
Research Preparation Form Tracked Version 07.21.2014
Research Using Decedents' Information Form Tracked Version 10.23.2013
Tissue Bank Management Plan Template   01.18.2012
VA Criteria vs. Affiliate Form   02.21.2012
Other Stamped Documents
FORMS Tracked Changes Version Date
None    
"What Are These Documents For?" Guides
FORMS Tracked Changes Version Date
Consent Cover Letter Instructions for Use [PDF]  N/A 06.29.2015
Short Form Consent Instructions for Use, etc. [PDF] N/A 07.09.2012
IRB Guidance: Consent Process Models N/A  
Last Updated: 1/11/17