Skip to Main Content

You are here:

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 08.21.2018
Consent and Authorization Document (for Minimal Risk Research) Template Tracked Changes 08.21.2018
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 08.21.2018
Parental Permission and Authorization Document (for Minimal Risk Research) Template Tracked Changes 08.21.2018
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 Short Form Consent Documents
    Please click here to go to the Short Forms page.

 

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
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)

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
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
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: 8/21/18