UW Research
Forms and Templates

External Reliance HIPAA Waiver Request


In rare circumstances, a non-UW IRB will not consider or grant HIPAA waivers (either in full or in part) for UW research that is under its oversight. In these circumstances, a member of the UW IRB can consider and grant the HIPAA waivers that are required for the conduct of the research. This form is designed to collect supplemental information about the planned use of PHI in order for the IRB member to complete that task.

The completed Supplement should be provided to HSD only when directed by HSD staff.

Change Notes

Add records retention confirmation question – 07.27.2023
New supplement – 06.29.2023