Office of the Institutional Review Board

All (A - Z) Forms

Instructions:

  • Always download the forms from the IRB website to ensure you are using the most current versions.
  • All submissions to the IRB should be sent via the IRBmail@uthscsa.edu mailbox.
  • Hard copy submissions are not accepted.
Form Instructions MS Word/ PDF

GLOSSARY OF OIRB TERMS

 

IRB Online Glossary

10-9012, VA Form - Investigational Drug Information Record (Form Inst-F)

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Adverse Event Reporting / UPIRSO Reporting
(Prompt Reporting Form)

(Use AE form if event resulted in physical or psychological harm) -Click this link for Help Determining whether an AE is an Unanticipated problem

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Adverse Event Tracking Form (Track both UPIRSO and Events and Problems Not Requiring Prompt Reporting)

Optional form. For use when no pre-existing tracking system capable of producing reports is available.

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Agreement for Investigators Who are Not Affiliated with One of the Institutions Subject to UTHSCSA IRBs for All Research
     (One Non-Affiliated Investigator, One Study)

  One Non-Affiliated Investigator, One Study Agreement Form (pdf)

Agreement for Investigators Who are Not Affiliated with One of the Institutions Subject to UTHSCSA IRBs for All Research
    (Multiple Non-Affiliated Investigators, One Study)

  • Submit:
    • Signed Part A for each unaffiliated investigator
    • Signed Part B for each study listing all unaffiliated investigators

Part A (pdf)

Part B (pdf)

Alteration to Consent

This is a BLANK template for when consent will be obtained but not all required elements of consent will be presented to the subject (i.e., verbal consent)

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Amendment to Human Use Protocol

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Assent Waiver Request

 

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Assurance for Research on Decedent's Information

Form J-1 - This document is used to notify the IRB that an investigator plans to use or disclosure PHI of decedents (deceased persons); to assure the IRB that it is being requested solely for the purpose of research on the PHI of decedents for the Research Project described; and to assure the IRB that it is necessary for conduct of this Research Project. The researcher agrees that upon request by UTHSCSA or affiliated institution’s Covered Component from whom the PHI is sought, he/she will provide documentation establishing that the Individual’s(s’) whose PHI is/are being requested is/are deceased.

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Assurance Letter

A letter containing the UTHSCSA FWA number, numbers of the IRBs listed under this FWA and a list of affiliated institutions covered by the IRB under general IRB Authorization Agreements.

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Billing Grid This is not an IRB template. Submit if any clinical services are being used to provide conventional patient care or research procedures.  
Budget (Study Budget) This is not an IRB template. Include the study budget (if applicable) with your submission.  
Certification from Independent Physician for Emergency Use   doc for PC
Child Protective Services, Research Involving
(Texas Department of Family and Protective Services Request for Approval) (Form Inst-J)
For research involving Child Protective Services doc for PC

Children (Request for Research Involving Children) (Form W)

 

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Clinical Trial Agreement This is not an IRB template. Include the clinical trial agreement (if applicable) with your submission.  

Conflict of Interest (COI) (Protocol Related COI) (Form X)

See HOP Conflicts of Interest in Scholarly, Research, and Clinical Activity, HOP Conflict of Commitment, and HOP Institutional Conflict of Interest Policy as applicable.

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Consent (Form D)

For non-VA studies only.
Combined research consent + HIPAA authorization.
For research studies contributing to another repository, refer to the informed consent instructions for repositories.

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Consent and Authorization for Pregnant Partners of Participants

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CONSENT- SHORT FORM - ENGLISH

Submit an amendment to request IRB approval to utilize a SHORT FORM consent process for potential subjects or LARs that are non-English speaking and there is not enough time to obtain a translation (the English version is provided here to be translated in the appropriate language).

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CONSENT- SHORT FORM - SPANISH

Submit an amendment to request IRB approval to utilize a SHORT FORM consent process for potential subjects or LARs that are non-English speaking and there is not enough time to obtain a translation. This is the Spanish version.

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Consent Template for Emergency Treatment Use of Investigational Drugs Biologics or Devices

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Continuing Review (Progress Report Form)

 

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Copy of package insert or FDA approved label (PDR reference) (Form S)

Included for drug or device studies with study directed use of FDA approved medication/device for approved medical indication.

 

CTRC Review Committee (Formerly SACI) (Form HH)

No longer referred to as SACI Review Committee. See Form HH - CTRC Review Committee.

 

Data and Safety Monitoring Plan (Form R Monitoring Participant Safety and Data Integrity)

 

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Deceased persons PHI: Form J-1 Assurance for Research on Decedent's Information

Form J-1 - This document is used to notify the IRB that an investigator plans to use or disclosure PHI of decedents (deceased persons); to assure the IRB that it is being requested solely for the purpose of research on the PHI of decedents for the Research Project described; and to assure the IRB that it is necessary for conduct of this Research Project. The researcher agrees that upon request by UTHSCSA or affiliated institution’s Covered Component from whom the PHI is sought, he/she will provide documentation establishing that the Individual’s(s’) whose PHI is/are being requested is/are deceased.

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Decisionally Impaired (Request for Research Involving) (Form T)

 

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Deviations Tracking Log

 

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Device Form (including Humanitarian Use Device) (Form P)

 

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Device proposal and/or the sponsor’s contract (Form DD)

This is not an IRB template. Include the form (if applicable) with your submission.

 

Drug - Emergency use - Consent

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Drug Information Record (Investigational Drug Information Record) (Form Inst-F)

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DSMP (Form R Monitoring Participant Safety and Data Integrity)

 

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Durable Power of Attorney for Health Care - sample forms

Patient-Centered Guides: Durable Power of Attorney

Webpage

Durable Power of Attorney for Health Care sample forms

Internet Legal Research Group

Webpage

Durable Power of Attorney for Health Care sample forms

Internet Legal Research Group - Forms

Webpage

Emergency ID Card (Sample)

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Emergency Use of Investigational Drugs Biologics or Devices-Consent Template

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Emergency Use - Certification from Independent Physician   doc for PC
Emergency Use - IRB Notification Form   doc for PC
Emergency Use (Drug) Checklist   doc for PC
Emergency Use (Device) Checklist   doc for PC

Exception Request Form

Refer to the Modifications and Amendments Policy and Procedure

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Exempt Research Request - General Information Sheet (Form B-3)

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Expedited Certification Form (Form B-1)

 

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FDA approved label (PDR reference) (Form S Copy of package insert)

Included for drug or device studies with study directed use of FDA approved medication/device for approved medical indication.

 

Fetuses (Form U)

Form U - Research Involving Pregnant Women, Fetuses, &/or Neonates

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Final Report (Formerly Final Report, now "Request for Inactivation")

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Find a Study Recruitment Website (Form L-1) Complete if you wish the study to be posted on the Find a Study website. doc for PC

Form A - 1 Multipurpose Signature Assurance Sheet

Should be submitted with all forms required after approval (amendments, progress reports, prompt reporting).

How to digitally sign Adobe forms.

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Form A - Signature Assurance Sheet

Required for initial submission.

How to digitally sign Adobe forms.

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Form AA - Grant Application

This is not an IRB template. Include the document (if applicable) with your submission.

 

Form B-1 - Expedited Certification Form

 

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Form B-3 - Exempt Research Request - General Information Sheet

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Form BB - Sponsor's protocol

This is not an IRB template. Include the document (if applicable) with your submission.

 
Form BC - Protocol Template Form Use this template form if you do not have a sponsor's protocol. doc for PC

Form C-1 - Local Repository Description

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Form CC - Investigator Brochure

This is not an IRB template. Include the document (if applicable) with your submission.

 

Form D - Research Consent

For non-VA studies only.
Combined research consent + HIPAA authorization.
For research studies contributing to another repository, refer to the informed consent instructions for repositories.

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Form D-1 - VA Research Consent

For VA studies and studies where VA is a site.
Research consent only (does not include HIPAA authorization - Refer to Forms H-UT & H-VA)

For research studies contributing to another repository, refer to the informed consent instructions for repositories.

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Form D-2 - Spanish Research Consent

 

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Form D-PP - Pregnant Consent and Authorization For studies collecting pregnancy outcomes of participants who inadvertently become pregnant or the participant’s partner who becomes pregnant. doc for PC

Form D-IS (Information Sheet)

Template to use when developing informatiton sheet. Differs from consent in that it does not contain a signature section.

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Form D Withdrawal Use this form for continued follow-up after withdrawal from interventions. doc for PC

Form DD - Device proposal and/or the sponsor’s contract

This is not an IRB template. Include the document (if applicable) with your submission.

 

Form E - Repository Consent

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Form E-1 - VA Repository Consent

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Form E - 2 - Spanish Repository Consent

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Form EE - Institutional Biosafety Committee (IBC)

This is not an IRB template. Include the document (if applicable) with your submission.

 

Form F - BLANK Template

This is a BLANK template for one of the following: (1) Alteration to Consent (not all required elements of consent will be presented) (2) Waiver of Informed Consent Process (When consent is not obtained) (3) Waiver of Documentation of Informed Consent Process (consent will be obtained but a signature will not)

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Form F - EFIC (Exception from Informed Consent)   doc for PC

Form F - SAMPLE waiver of consent for Chart Review Study

This is PRE-POPULATED form which contains acceptable template wording when requesting a waiver of consent to complete a chart review study.

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Form F - SAMPLE Alteration and waiver of documentation of consent for research procedures prior to full consent

This is PRE-POPULATED form which contains acceptable template wording when requesting an alteration and waiver of signature to obtain abbreviated verbal consent for procedures completed prior to full informed consent (e.g. request subject to attend screening visit in fasting state)

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Form F - SAMPLE waiver of consent for Recruitment

This is PRE-POPULATED form which contains acceptable template wording when requesting a waiver of consent to identify eligible subjects for recruitment.

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Form G - Model Consent Form

This is not an IRB template. Include the document (if applicable) with your submission.

 

Form GG - Applicable Radiation Safety Committee

This is not an IRB template. Include the document (if applicable) with your submission.

 

Form H-1 Translation Certification Form

To be turned in with translated consent form. Pertains to subjects from any foreign culture.

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Form HH - CTRC Review Committee

This is not an IRB template. Include the document (if applicable) with your submission.

 
Form H-UT - UT HIPAA Authorization Authorization for Use & Release of Individually Identifiable Health Information.
Use with Form D-1 for non-VA sites.
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Form H-VA - VA HIPAA Authorization
(VA form 10-0493)
Authorization for Use & Release of Individually Identifiable Health Information for Veterans Health Administration (VHA) Research
Use with Form D-1 for VA sites.
Related Form: VA Revocation (10-10116)
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Form H-VA - VA HIPAA Authorization - Spanish Version Authorization for Use & Release of Individually Identifiable Health Information for Veterans Health Administration (VHA) Research - Spanish Version pdf for PC

Form I - HIPAA De-identification Agreement Form

Complete Form I if a covered entity will remove the identifiers. The de-identified data or specimens will be released to the PI from a covered entity.

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Form II - Radioactive Drug Research Committee

This is not an IRB template. Include the document (if applicable) with your submission.  

Form Inst-F - Investigational Drug Information Record

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Form Inst-G - Pharmacy LOU   doc for PC
Form Inst-H - Local Sponsor-Investigator Monitoring Plan   doc for PC
Form Inst-J - Child Protective Services, Research Involving
(Texas Department of Family and Protective Services Request for Approval)
For research involving Child Protective Services doc for PC
Form Inst-M - Personnel Form   doc for PC

Form J - HIPAA Waiver of Authorization

 

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Form J-1 - Assurance for Research on Decedent's Information

Form J-1 - This document is used to notify the IRB that an investigator plans to use or disclosure PHI of decedents (deceased persons); to assure the IRB that it is being requested solely for the purpose of research on the PHI of decedents for the Research Project described; and to assure the IRB that it is necessary for conduct of this Research Project. The researcher agrees that upon request by UTHSCSA or affiliated institution’s Covered Component from whom the PHI is sought, he/she will provide documentation establishing that the Individual’s(s’) whose PHI is/are being requested is/are deceased.

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Form K-1 - UT System Centralized IRB Review

Use this form when you are collaborating with researchers from another UT system Institution and plan to request a centralized IRB review. This form needs to be completed for UTHSCSA researchers and submitted to other UT system Institution with the research application. pdf for PC
Form K-2 - Intent to Rely Form
(Centralized IRB Review)
This form should be completed to document centralized IRB review under a Broad or Reciprocal agreement. This form helps to ensure any outstanding concerns or requirements by the Deferring Site are addressed before the study is approved by the Reviewing IRB. pdf for PC

Form L - Proposed advertisement(s) of any type for recruiting

This is not an IRB template. Include the document (if applicable) with your submission. Guidelines for Advertising

 
Form L-1 - Find a Study Recruitment Website Complete if you wish the study to be posted on the Find a Study website. doc for PC

Form M - Proposed data collection instrument(s) used to record data (i.e., CRF, Excel spreadsheet, survey, questionnaire)

This is not an IRB template. Include the document (if applicable) with your submission.

 

Form O - Use of a Drug in Research

 

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Form O-2 - Use of a Placebo in Place of Standard Therapy

 

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Form P - Use of Investigational Device Form (May be Exempt from IDE) (including Humanitarian Use Device)

 

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Form Q - Use of Radiation in Human Research (Radiation Exposure Worksheet)

 

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Form Q-1 - Gene Transfer Therapy in Human Research Studies   doc for PC

Form R - Monitoring Participant Safety and Data Integrity

 

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Form S - Copy of package insert or FDA approved label (PDR reference)

Included for drug or device studies with study directed use of FDA approved medication/device for approved medical indication.

 

Form T - Research Involving the Decisionally Impaired

 

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Form tA (Treatment Use)

For use in a form of Expanded Access called "Treatment Use" or Investigational Treatment Use of an Unapproved drug/device.

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Form tB - General Information Sheet (Treatment Use)

For use in a form of Expanded Access called "Treatment Use" or Investigational Treatment Use of an Unapproved drug/device.

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Form tB-2 - Study Personnel List (Treatment Use)

For use in a form of Expanded Access called "Treatment Use" or Investigational Treatment Use of an Unapproved drug/device.

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Form tC - Research Description (Treatment Use)

For use in a form of Expanded Access called "Treatment Use" or Investigational Treatment Use of an Unapproved drug/device.

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Form tD - Research Consent For use in a form of Expanded Access called "Treatment Use" or Investigational Treatment Use of an Unapproved drug/device. doc for PC

Form tO - Investigational New Drug (Treatment Use)

For use in a form of Expanded Access called "Treatment Use" or Investigational Treatment Use of an Unapproved drug/device.

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Form tO-1 - Approved Drug Unapproved Use (Treatment Use)

For use in a form of Expanded Access called "Treatment Use" or Investigational Treatment Use of an Unapproved drug/device.

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Form tP - Investigational Device (Treatment Use)

For use in a form of Expanded Access called "Treatment Use" or Investigational Treatment Use of an Unapproved drug/device.

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Form U - Research Involving Pregnant Women, Fetuses, &/or Neonates

 

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Form U - Pregnant Women, Neonates, Fetuses- describing Follow up only

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Form V - Research Involving Prisoners

 

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Form W - Research Involving Children

 

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Form X - Protocol Related Conflict of Interest (COI) Report

See HOP Conflicts of Interest in Scholarly, Research, and Clinical Activity, HOP Conflict of Commitment, and HOP Institutional Conflict of Interest Policy as applicable.

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Form Y - Monitoring Plan - Lead PI

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Gene Transfer Therapy in Human Research Studies
(Form Q-1)
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GLOSSARY OF OIRB TERMS

  IRB Online Glossary

Grant Application (Form AA)

This is not an IRB template. Include the document (if applicable) with your submission.

 
Greater Plains Collaborative Reliance Checklist (GPC Reliance Checklist) Use this form when you are collaborating with researchers from an Institution that is part of the Greater Plains Collaborative Reciprocity Agreement. This form will need to be completed by the relying institution. pdf for PC

HDE Progress Report Form

 

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HIPAA Authorization UT (Form H-UT) Authorization for Use & Release of Individually Identifiable Health Information.
Use with Form D-1 for non-VA sites.
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HIPAA Authorization VA (Form H-VA)
(VA form 10-0493)
Authorization for Use & Release of Individually Identifiable Health Information for Veterans Health Administration (VHA) Research
Use with Form D-1 for VA sites.
Related Form: VA Revocation (10-10116)
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HIPAA Authorization VA (Form H-VA) Spanish Version Authorization for Use & Release of Individually Identifiable Health Information for Veterans Health Administration (VHA) Research - Spanish Version pdf for PC

HIPAA De-identification Agreement Form
(Form I)

Complete Form I if a covered entity will remove the identifiers. The de-identified data or specimens will be released to the PI from a covered entity.

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HIPAA Waiver of Authorization (Form J)

Waiver of Authorization Guidance.

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HUD Initial Request Form   doc for PC

Humanitarian Use Device (Form P)

 

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Impaired Subjects (Form to request inclusion) (Form T)

 

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Incompetent Subjects (Form to request inclusion) (Form T)

 

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Institutional Biosafety Committee (IBC) (Form EE)

This is not an IRB template. Include the document (if applicable) with your submission.

 

Internet Legal Research Group

Durable Power of Attorney for Health Care sample forms

Webpage

Internet Legal Research Group - Forms

Durable Power of Attorney for Health Care sample forms

Webpage

Investigational Drug Information Record (Form Inst-F)

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Investigator Brochure (Form CC)

This is not an IRB template. Include the document (if applicable) with your submission.

 

IRB Authorization Agreement Form

Contact the IRB Director if you need to negotiate an agreement.

 
Leaving the University - Request to Transfer Research Data, Tangible Research Property or Equipment When Leaving the University   pdf for PC

Letters of Support or Memorandum of Understanding for Off-site Research

This is not an IRB template. Include the letters (if applicable) with your submission.

 

Local Repository Description (Form C-1)

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Local Sponsor-Investigator Monitoring Plan (Form Inst-H)   doc for PC

Log for Tracking Adverse Events (Track both UPIRSO and Events and Problems Not Requiring Prompt Reporting)

Optional form. For use when no pre-existing tracking system capable of producing reports is available.

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Model Consent Form (Form G)

This is not an IRB template. Include the document (if applicable) with your submission.

 

Modification to Human Use Protocol

See also Amendment

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Monitoring Participant Safety and Data Integrity (Form R)

 

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Monitoring Plan - Lead PI (Form Y)

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Multipurpose Signature Assurance Sheet (Form A-1)

Should be submitted with all forms required after approval (amendments, progress reports, prompt reporting).

How to digitally sign Adobe forms.

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Neonatal Research (Viability not in question)

 

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Neonates - Nonviable (Form U)

Form U - Research Involving Pregnant Women, Fetuses, &/or Neonates

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Neonates of uncertain viability (Form U)

Form U - Research Involving Pregnant Women, Fetuses, &/or Neonates

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Non-Adverse Event / UPIRSO Reporting for Non-AE
(Prompt Reporting Form)

(Use Non-AE form where no physical or psychological harm resulted whether medical or nonmedical event) -Click here for Help Determining whether a non_AE is an Unanticipated problem

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Noncompliance Reporting
(Prompt Reporting Form)

Used to self report noncompliance with federal regulations or IRB Policies as well as major deviations.

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Non-Human Research, Request for Review   doc for PC
Non-Regulated Research Project, Request for Review   doc for PC

Package insert or FDA approved label (PDR reference) (Copy)

Included for drug or device studies with study directed use of FDA approved medication/device for approved medical indication.

 

Parental Permission - Request for Waiver

 

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Patient-Centered Guides: Durable Power of Attorney

Durable Power of Attorney for Health Care - sample forms

Webpage
Payment Schedule / Payment Form
(Subject Payment Schedule/Participant Payment Form)
To be used if you plan to pay enrolled subjects. This is a CTO template.
A Mac version of this CTO form is also available.
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Personnel Form (Form Inst-M)   doc for PC
Pharmacy LOU (Form Inst-G)   doc for PC

Placebo In Place of Standard Therapy (Form O-2)

 

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Pregnant Women (Form U)

Form U - Research Involving Pregnant Women, Fetuses, &/or Neonates

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Pregnant Women, Neonates, Fetuses- describing Follow up only

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Pregnant Consent and Authorization (Form D-PP) For studies collecting pregnancy outcomes of participants who inadvertently become pregnant or the participant’s partner who becomes pregnant. doc for PC

Prisoners (Request for Research Involving) (Form V)

 

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Progress Report Form

 

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Progress Report Form for Repository

 

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Progress Report Form-HDE

 

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Proposed advertisement(s) of any type for recruiting (Form L)

This is not an IRB template. Include the document (if applicable) with your submission. Guidelines for Advertising

 

Proposed data collection instrument(s) (i.e. survey(s) questionnaire(s)) (Form M)

This is not an IRB template. Include the document (if applicable) with your submission.

 

Protocol Deviations Tracking Log

 

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Protocol Related Conflict of Interest (COI) (Form X)

See HOP Conflicts of Interest in Scholarly, Research, and Clinical Activity, HOP Conflict of Commitment, and HOP Institutional Conflict of Interest Policy as applicable.

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Protocol Template Form (Form BC) Submit this form if applicable to your research. Use this template form if you do not have a sponsor's protocol. doc for PC

Radiation in Human Research (Radiation Exposure Worksheet) (Form Q)

 

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Radiation Safety Committee (Form GG) This is not an IRB template. Include the approval letter (if applicable) with your submission.  

Radioactive Drug Research Committee (Form II)

This is not an IRB template. Include the approval letter (if applicable) with your submission.  
Re-Activation form Submit this form if you wish to request to re-initiate a research study. doc for PC
Recruitment Website (Find a Study - Form L-1) Complete if you wish the study to be posted on the Find a Study website. doc for PC
Rely, Form K-2 - Intent to Rely Form
(Centralized IRB Review)
This form should be completed to document centralized IRB review under a Broad or Reciprocal agreement. This form helps to ensure any outstanding concerns or requirements by the Deferring Site are addressed before the study is approved by the Reviewing IRB. pdf for PC

Reporting Noncompliance
(Prompt Reporting Form)

Used to self report noncompliance with federal regulations or IRB Policies as well as major deviations.

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Repository Consent (Form E )

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Repository Progress Report Form

 

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Repository Spanish Consent (Form E - 2)

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Repository VA Consent (Form E-1)

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Request for Inactivation (Formerly "Final Report")

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Request for Research Involving Prisoners (Form V)

 

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Request for Review of Project not Involving Regulated Research   doc for PC
Request for Review of Research not Involving Human Subjects   doc for PC

Research Consent (Form D)

For non-VA studies only.
Combined research consent + HIPAA authorization.
For research studies contributing to another repository, refer to the informed consent instructions for repositories.

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Research Involving Children (Form W)

 

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Research involving healthy neonates (Viablility not in question)

 

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Research Involving the Decisionally Impaired (Form T)

 

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Schedule of Events This is not an IRB template. Include the schedule of events (if applicable) with your submission.  

Signature Assurance Sheet (Form A)

Required with initial submission.

How to digitally sign Adobe forms.

pdf for PC

Signature Assurance Sheet-Multipurpose (Form A-1)

Should be included with all forms required after approval (amendments, progress reports, prompt reporting)

How to digitally sign Adobe forms.

pdf for PC

Spanish Repository Consent - Form E - 2

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Spanish Research Consent (Form D-2)

 

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Sponsor’s protocol (Form BB)

This is not an IRB template. Include the document (if applicable) with your submission.

 

Step 1 Research Common Application Form

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Step 2 Research Common Application Institutional Form

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Step 2 Research Common Application Continuation UTHSCSA IRB Application   doc for PC

Telephone Script

This is not an IRB template. Include the document (if applicable) with your submission.

 
Texas Department of Family and Protective Services Request for Approval (Form Inst-J) For research involving Child Protective Services doc for PC

Tracking Log for Events and Problems (Track both UPIRSO and Events and Problems Not Requiring Prompt Reporting)

Option form. For use when no pre-existing tracking system capable of producing reports is available.

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Tracking Log for Protocol Deviations

 

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Transfer Research Data - Request to Transfer Research Data, Tangible Research Property or Equipment When Leaving the University   pdf for PC

Translation Certification for consent forms requiring translation

Pertains to subjects from any foreign culture

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UPIRSO Reporting / Adverse Event (Resulted in physical or psychological harm)
(Prompt Reporting Form)

(Use AE form if event resulted in physical or psychological harm) -Click this link for Help Determining whether an AE is an Unanticipated problem

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UPIRSO Reporting / Non-Adverse Event (Medical or nonmedical but no physical or psychological harm resulted)
(Prompt Reporting Form)

(Use Non-AE form where no physical or psychological harm resulted whether medical or nonmedical event) -Click here for Help Determining whether a non_AE is an Unanticipated problem

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UPIRSO Tracking Log for Events and Problems (Track both UPIRSO and Events and Problems Not Requiring Prompt Reporting)

Option form. For use when no pre-existing tracking system capable of producing reports is available.

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UT HIPAA Authorization (Form H-UT) Authorization for Use & Release of Individually Identifiable Health Information.
Use with Form D-1 for non-VA sites.
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UT System Centralized IRB Review (Form K-1)

Use this form when you are collaborating with researchers from another UT system Institution and plan to request a centralized IRB review. This form needs to be completed for UTHSCSA researchers and submitted to other UT system Institution with the research application.

pdf for PC
VA HIPAA Authorization (Form H-VA)
(VA form 10-0493)
Authorization for Use & Release of Individually Identifiable Health Information for Veterans Health Administration (VHA) Research
Use with Form D-1 for VA sites.
Related Form: VA Revocation (10-10116)
pdf for PC
VA HIPAA Authorization (Form H-VA) Spanish Version Authorization for Use & Release of Individually Identifiable Health Information for Veterans Health Administration (VHA) Research - Spanish Version pdf for PC

VA Repository Consent (Form E-1)

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VA Research Consent (Form D-1)

For VA studies and studies where VA is a site.
Research consent only (does not include HIPAA authorization - Refer to Forms H-UT & H-VA)

For research studies contributing to another repository, refer to the informed consent instructions for repositories.

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Waiver of Assent Request

 

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Waiver of Documentation of Informed Consent Process

This is a BLANK template for when consent will be obtained but a signature will not (i.e., verbal consent)

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Waiver of Informed Consent Process

This is a BLANK template for when consent will not be obtained (written or verbally)

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Waiver of Parental Permission

 

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Withdrawal (Form D Withdrawal) Use this form for continued follow-up after withdrawal from interventions. doc for PC
     

   

 

Note:  These forms are to be downloaded and saved to your computer and then opened in Microsoft Word (Click the picture for an example).  If you are experiencing problems downloading a form from our page, and using an alternate browser has not helped (i.e., Firefox, Chrome, Internet Explorer), please call the Office of the IRB at 210-567-8250. Example