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Human Subjects Division (HSD)


Document Details

Last Updated 05/31/2016
Version 1.40
Filesize 156.5 KB
Audiences HSD Staff, IRB Member, Researcher
Doc Type Form

PAPER SUPPLEMENT: Waiver Request, HIPAA Authorization


Use this form to request a waiver of the requirement for HIPAA Authorization. This means that you are requesting permission to access, obtain, use or disclose a research subject's Protected Health Information (PHI) for research purposes without obtaining the subject's specific authorization for that access, use or disclosure.

This document is for use with paper-based applications only. Do not use with Zipline. HSD accepts versions from 3/27/2015 on.

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Change Notes

  • Related to Ver. 1.30, noted 03/05/2015 @ 11:04am
    Harmonized version, date and title across form and web. Okay to use previous version.
    - sherrye
  • Related to Ver. 1.20, noted 10/19/2013 @ 04:51pm
    Updated name to new naming convention on website.
    - sherrye
  • Related to Ver. 1.20, noted 05/27/2011 @ 09:44am
    Addition of double-sided copies instructions.
    - sherrye