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Forms & Templates

Informed Consent Index

Find the new informed consent guidance resources here.

Consent Document Checklist

Learn more about how to create a consent document for your research study.

Concise Summary Guidance

Guidance and models to help you write your consent document concise summary.

Translated Consent Documents

Translated short form consent documents can be found here.


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

Consent Documents
These templates are no longer available.

where are the consent document templates?

NOTE: If you submit your consent documents to the IRB as a Word Document, the watermark footer field is still required.  If you submit your documents as an Adobe PDF, the watermark field is NOT required, but you should leave 2" of blank space at the bottom of the document to leave room for the IRB approval image.

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Consent Language & Supplements
FORMS Tracked Changes Version Date
Assent Document Template Tracked Changes 02.08.2012
Blank Watermark Document   02.01.2019
CCTS Consent Executive Summary Template (CCTS Document) Tracked Changes 01.03.2014
Debriefing Document Template Tracked Changes 07.20.2011
Tissue/Specimen Banking Consent Language Tracked Changes 09.15.2013
Signature Block Samples   02.01.2019
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

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VA Documents and Forms
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

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Recruitment Materials
FORMS Tracked Changes Version Date
Recruitment Letter Template   05.14.2010
Simple Referral Template   05.14.2010

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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

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External Sites and Agreements
FORMS Tracked Changes Version Date
Data Use Agreement (DUA) Template - UUHSC - Please contact the Technology & Venture Commercialization (TVC)   N/A
Data Use Agreement (DUA) Template - IHC   06.09.2008
Information for Accounting of Disclosures Template   11.20.2011
Material Transfer Agreement (MTA) Template- Please contactTechnology & Venture Commercialization (TVC)   N/A
Privacy Protection Verification for Research Conducted in Schools N/A

08.15.2017
(H1517)

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Other Documents
FORMS Tracked Changes Version Date
Agreement for Public Ethnographic Studies   N/A
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 (DoD) Supplement Form  Tracked Version 05.15.2019
Exclusion of Research Data in EMR Request Form - Available on Pulse (University employee access only)
University of Utah Health Form Only; This is not a requirement of all studies that use the University of Utah IRB.  
  N/A
Exemption Umbrella Annual Report Template   09.01.2013
Expired Study Continuation Request Form Tracked Version 08.13.2018
Payment Process Exception Request Form   01.03.2012
Quarterly Report Template Tracked Version 01.03.2012
Report Form for Public Ethnographic Studies   N/A
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
Last Updated: 5/17/19