Office of the Institutional Review Board

Miscellaneous Forms

Disclosure of PHI of Decedents

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.

Documents Related to Consent

Consent Short Form

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.
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.
Form D Withdrawal Use this form for continued follow-up after withdrawal from interventions.
Form H-1 - Translation Certification Form To be turned in with translated consent form. Pertains to subjects from any foreign culture.

Forms Related to Pregnant Women, Neonates, Fetuses

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

Individual Investigator Agreements

Individual Investigator Agreement

One Non-Affiliated Investigator, One Study. For Researchers not affiliated with UT Health San Antonio.

Individual Investigator Agreement (modified for multiple investigators)

Multiple Non-Affiliated Investigators, One Study. For Researchers not affiliated with UT Health San Antonio.
  • Signed Part A for each non-affiliated investigator
  • Signed Part B for each study listing all non-affiliated investigators

Transfer Research Data When Leaving the University

Transfer Research Data Form Request to Transfer Research Data, Tangible Research Property or Equipment When Leaving the University

Medical Directive & Power of Attorney

Medical Directive Information about Advance Medical Directive from Prepare for your Care website

Power of Attorney

Information about Medical Power of Attorney, Statutory Durable Power of Attorney from Texas Health and Human Services website

Optional Forms / Samples / Documents To Be Used By The Study Team

Emergency ID Card

sample of emergency ID card

PI-SA Survey for website

PI Self Assessment Survey with Corrective Actions-EXAMPLE

Protocol Deviations Tracking Log Use this log to document all protocol deviations and track any subsequent reports to the IRB.
Tracking Log for Events and Problems 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.

 


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