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Institutional Review Board

U.S. Consent/HIPAA Authorization Forms and Medical Record Release
for Data Collection in a Covered Entity

Form Number

Adults

Signed Combined Consent/HIPAA Authorization Form_Adult

1

Oral Consent/HIPAA Authorization Form_Adult (must have HIPAA waiver of requirement for signature for HIPAA Authorization)

2

Medical Record Release/HIPAA Authorization_Adult

3

Parent/Legal Guardian Permission

Signed Combined Consent/HIPAA Authorization Form_Parent

4

Oral Parental Permission/HIPAA Authorization Form_Parent (must have HIPAA waiver of signature requirement)

5

Medical Record Release/HIPAA Authorization_Parent

6

Consent, Assent, Parental Permission Forms for All Other Data Collection – U.S and International

 

Adults

Signed Consent_Adult

7

Oral Consent Script_Adult

8

Children

Signed Assent

9

Oral Assent Script_Child 

10

Parent/Legal Guardian Permission

Signed Parental Permission

11

Oral Parental Permission Script

 

12

Consent for Storing Biospecimens for Future Research

 

Adults

Signed Consent_Adults

13

Parental Permission

Signed Parental Permission

14

Suggested Common Consent Form Language for Specific Studies

 

Genes, Cell Lines, and Genomes

Genomic Data Sharing Language

Focus Group Studies Language

Mandatory reporting for child abuse or neglect (usually for studies with home visits)

Radiation Risk Language

Survey/ Questionnaire Language