/ Blessing-Rieman College of Nursing
Institutional Review Board
Broadway at 11th • PO Box 7005 • Quincy, Illinois • 217-228-5520
Blessing Hospital Privacy Board

Request for Review Preparatory to Research

  1. Purpose of This Form

The purpose of this form is to inform the Institutional Review Board (IRB) or Privacy Board that your project involves the collection of data protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The HIPAA Privacy Rule requires researchers to make certain representations before Protected Health Information (PHI) can be used or disclosed for review preparatory to research. This document assists a researcher in making and recording these required representations. The role of the Blessing-Rieman College of Nursing (BRCN) IRB is to act as a Privacy Board as required by federal regulations to review the use and disclosure of PHI for review preparatory to research. This form will be returned to you as documentation of your project having been reviewed by the Privacy Board.

  1. How to Complete This Form
  1. Save a copy of this form to your computer or laptop.
  2. Fill out all items of this form. Incomplete or incorrectly completed forms will be returned to the principal investigator.
  3. The form must be typed. Hand written forms will not be accepted.
  4. Submit this form as a WORD document; do not convert it to a different file format such as PDF.
  5. If you are submitting a separate application for IRB approval for this project, complete and submit this form along with your IRB application to the BRCN IRB at .
  1. Required Information

Date of Request

Principal Investigator (Full Name)

Researcher Affiliation

Official Title of Research Project

Business Address (Street/PO Box/City/State/Zip)

Research Phone Numbers

Researcher Email

Financial Sponsor (Name/Address/City/State/Zip/Phone/Email)

Provide a brief description of the research project

Explain why PHI is required preparatory to research.

Please clearly list the minimal amount of PHI necessary to for your review preparatory to research. The PHI indicated in your response must be consistent with the more extensive list of all data elements provided in your project proposal, HIPAA form and any IRB application.

  1. Required Representations

As Principal Investigator of the research project indicated on this form, I make the following assurances to the BRCN Privacy Board: (please print the entire form, initial each assurance below, provide signature and date below, print name below, and scan the form so that it may be attached to an email for submission.)

______The use or disclosure sought is solely to review PHI as necessary to prepare a research protocol or for similar purposes preparatory to research.

______No PHI will be removed from Blessing Health System in the course of this review.

______The PHI for which use or disclosure is sought is necessary for research purposes.

______I understand that the BRCN Privacy Board is an Institutional Review Board and is authorized to review and/or approve human subjects research regulated under the Common Rule.

______I understand that the above representations are binding upon and will inure to the benefit and obligation of the Principal Investigator of the research project indicated on this form and his or her respective successors and/or assigns.

______

Signature of Principal Investigator Date

______

PRINT Principal Investigator Name

FOR PRIVACY BOARD USE ONLY
Official Title of Research Project
The Privacy Board has taken the action for this Request for Review Preparatory to Research as circled below:
APPROVED DENIED
Attention Board Members: Designated BRCN Privacy Board member should print this entire form, circle Privacy Board action above, provide signature and date below, print name below, and scan the form so that it may be attached to an email and sent to Principal Investigator.
______
Signature of Designated BRCN Privacy Board Member Date
______
PRINT Name of Designated BRCN Privacy Board Member

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