Principal Investigator: Click once to type Principal Investigator's Name Here

Study Title:	Click once to type Title Here

The HIPAA Privacy Rule allows a covered entity to use protected health information to create information that is not individually identifiable health information. Please read the following statements to assure that the data set requested meets the de-identification criteria. Also, please attach a list of the specific criteria for data, records and/or specimens requested.

A de-identified data set (or de-identified specimens) may not include any of the following:

Names

Addresses other than state, and first three digits of the zip code (provided that this geographic unit contains more than 20,000 people)

All elements of date other than year, and all specific ages over 89 years

Telephone numbers

Fax numbers

Electronic mail addresses

Social security numbers

Medical record numbers

Health plan beneficiary numbers

Account numbers

Certificate/license numbers

Vehicle identifiers and serial numbers

Device identifiers and serial numbers

Web universal resource locators (URLs; web site addresses)

Internet protocol (IP) addresses

Biometric identifiers, including finger and voice prints

Full face photographic images and any comparable images

Any other unique identifying number, characteristic, or code

Any code used to link the de-identified data or specimens to identifiers must be held by the investigator in a secure manner. The code must not be derived from or related to information about the individual, and may not be otherwise capable of being translated so as to identify the research subject. The mechanism for re-identification must not be disclosed to any person outside of covered entity (the holder of the PHI from which the de-identified data was derived).

Please attach a list of the selection criteria for records required (e.g.; all breast cancer patients seen at SCCC), the dates of the records required (e.g.; clinic visits from January 1, 1998 through December 31, 2016), and data fields required for the research.

DATA AND/OR RECORDS NEEDED FOR RESEARCH PROTOCOL

Selection Criteria (e.g.; asthmatics seen is Asthma Clinic):

Click once to type here

Click once to type here

Dates of required records: from MM/DD/YYYY through MM/DD/YYYY

Anticipated sources of information (check all that apply)

Paper medical records

Electronic files

Source of Specimens: (Name of repository, types of specimens, etc.)

Other: Click once to type here

Data fields required (list fields required from an electronic data base, or list variables to be recorded from the paper record by the researcher)

Click once to type here

Required Signatures

Principal Investigator Receiving Data/Specimens

By submitting this form, the PI attests to the following:

-I declare that the requested information constitutes the minimum necessary data to accomplish the goals of the project/research.

-I agree that the health information that I am requesting is de-identified and will remain so, as required by the HIPAA Privacy Rule.

-I agree not to accept receipt of the de-identified data prior to obtaining the following certification by the holder of the PHI and review (for non-research/Non-human Research) and/or approval (for exempt research) by the UTSW IRB.

PI Name: Click once to type Principal Investigator's Name Here

________________________________	__________________

PI Signature	Date

Individual Providing De-Identified Data/Specimens

By signing this form, a member of the covered entity agreeing to remove the identifiers described above, attests to the following:

-I agree to remove the above named identifiers as required by the HIPAA Privacy Rule prior to releasing the de-identified data set or specimens to the principal investigator.

-I have no actual knowledge that the information remaining in the data or attached to the specimens after the above 18 identifiers are removed could be used alone or in combination with other information to identify the individual who is the subject of the information or specimen.

Name: Click once to type the name of the Individual Providing De-identified data/specimens

_______________________________	_______________

Signature of De-identifying individual	Date