Miscellaneous Forms
Note: These forms are best downloaded using Internet Explorer (IE) as your web browser but then click "Save" because they are best opened in Microsoft Word from after being saved to your computer (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., Netscape Navigator, Internet Explorer), please call the Office of the IRB at 210-567-2351.
Instructions:
Always return to this webpage to create new submissions for continuing review, amendments, reports of possible UPIRSO, etc. to ensure you are using the most current forms.
Agreement for Investigators Who are Not Affiliated with One of the Institutions Subject to UTHSCSA IRBs for All Research |
 |
||
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. |
 |
|
CONSENT- SHORT FORM (Illit).doc |
Use only after IRB approval to add the consent process that utilizes a SHORT FORM consent process for potential subjects or LARs that are unable to see or read English.Instructions for Short Form Consent-Engl Speaking Blind or Illiterate Subject |
|
|
Durable Power of Attorney for Health Care sample forms |
Patient-Centered Guides: Durable Power of Attorney |
|
|
Durable Power of Attorney for Health Care sample forms |
Internet Legal Research Group |
|
|
Durable Power of Attorney for Health Care sample forms |
Internet Legal Research Group - Forms |
 |
|
Emergency ID Card (Sample) |
|
 |
|
Example Form U - PregWomen Neonates Fetuses- describing Follow up only |
|
||
FDA Guidance for Industry: Establishing Pregnancy Exposure Registries |
|
||
Form H-1 - Translation Certification Form (turned in with translated consent fo |
(Pertains to subjects from any foreign culture) Form H-1-Instructions |
|
|
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. |
|
|
Instructions for Short Form Consent-non-Engl Speaking Subject-no translation.doc |
Used with CONSENT-SHORT FORM |
|
|
IRB Authorization Agreement Form |
Contact the IRB Director if you need to negotiate an agreement. | ||
Other Committee Approvals Information Sheet |
|
|
|
Partner Consent and Authorization |
|
||
Protocol Deviations Tracking Log |
Click here for-Instructions |
|
|
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. |
|