ࡱ> GIF%` 6bjbj"x"x 4<@@5 ZZZZZZZnT,n"  $]hiZZZaZZZZ =D.v\w0.Z\)Z@4))) )))nnn nnn nnnZZZZZZ Dartmouth College Dartmouth-Hitchcock Medical Center COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS REVIEW OF CLINICAL HEALTH INFORMATION IN PREPARATION FOR A FUTURE RESEARCH STUDY v.11/04/08 ******* CPHS contact information: cphs.tasks@Dartmouth.edu or 603-646-6482 ******* CPHS #: ____________ LOCAL PRINCIPAL INVESTIGATOR:  FORMTEXT       DEPT:  FORMTEXT       SECTION:  FORMTEXT       CO - INVESTIGATOR(S):  FORMTEXT       DEPT:  FORMTEXT       CONTACT PERSON:  FORMTEXT       EMAIL:  FORMTEXT       STUDY TITLE:  FORMTEXT       FUNDING SOURCE (SPONSOR):  FORMTEXT       SPONSOR PROTOCOL # AND VERSION DATE, OR FEDERAL AWARD #:  FORMTEXT       Definitions: "Review Preparatory to Research": This provision of the HIPAA Privacy Rule may be used, for example, to obtain information necessary to the design of a research study or to assess the feasibility of conducting a study. 45 C.F.R. 164.512(i)(1)(ii). Protected Health Information (PHI) means individually identifiable health information created or received by the Dartmouth Hitchcock Privacy Group (DHPG) that relates to the past, present, or future physical or mental health of the individual or the past, present, or future payment for the provision of health care to the individual. ______________________________________________________________________________ To conduct a review preparatory to research, please provide the CPHS with the following information. 1. Describe the purpose and methodology of your review preparatory to research:  FORMTEXT       2 Describe the specific data fields necessary for your review preparatory to research:  FORMTEXT       3. Describe the safeguards you intend to use to maintain the confidentiality of the PHI necessary for your review:  FORMTEXT       Note: You are responsible for creating appropriate physical, administrative, and technical safeguards to maintain the confidentiality of and to secure the data involved in your review preparatory to research. By signing this form you are making representations that: (A) Your use or disclosure is sought solely to review protected health information as necessary to prepare a research protocol or for similar purposes preparatory to research; (B) No PHI is to be removed from the DHPG by you in the course of review; (C) The PHI for which 9ghij   % 2 3 9 Q R õ}n\G)jh$?h:CJOJQJU^JaJ#ho.h:5CJOJQJ^JaJh:5CJOJQJ^JaJh5CJOJQJ^JaJh0ph5>*h0ph5 hCC.5hCC.hCC.hT5CJ\aJhCC.h5CJ\aJhCC.h5CJ\aJhCC.h(A\hCC.h\ h\hbhCC.\h hbh h0ph9hij  2 |mm$ %0*3a$gdCC.gd%-$ %$d%d&d'dNOPQa$gd* %$d%d&d'dNOPQgd $ %3a$gd$  P !%3a$gd 62 3  0 pq %gd~gd%  %]gdT %gd^gd: %3dh<gd: P !%3dh<gd: P !%3dh<gdR \ ]    4 6 8 B D H \ ^ §n§`N:&jhCC.5CJOJQJU^JaJ#hCC.hCC.5CJOJQJ^JaJhCC.CJOJQJ^JaJ/jth$?h:CJOJQJU^JaJh:5CJOJQJ^JaJ#ho.h:5CJOJQJ^JaJ4jh$?h:CJOJQJU^JaJmHnHu)jh$?h:CJOJQJU^JaJ/jh$?h:CJOJQJU^JaJ h$?h:CJOJQJ^JaJ^ r t v ©—sbJs/s4jh$?h:CJOJQJU^JaJmHnHu/j\h$?h:CJOJQJU^JaJ h$?h:CJOJQJ^JaJ)jh$?h:CJOJQJU^JaJh:5CJOJQJ^JaJ#ho.h:5CJOJQJ^JaJ1jhCC.5CJOJQJU^JaJmHnHu&jhCC.5CJOJQJU^JaJ2jhCC.h^5CJOJQJU^JaJhCC.5CJOJQJ^JaJ   " . 0 2 F H J T V Z f h j ~ ϺϢxϺ`xϺH/jh$?h:CJOJQJU^JaJ/jDh$?h:CJOJQJU^JaJh:5CJOJQJ^JaJ4jh$?h:CJOJQJU^JaJmHnHu/jh$?h:CJOJQJU^JaJ)jh$?h:CJOJQJU^JaJ h$?h:CJOJQJ^JaJ#ho.h:5CJOJQJ^JaJh:CJOJQJ^JaJ   " , . 0 ǯؔ؃kؔWE#hh:5CJOJQJ^JaJ&ho.h:5>*CJOJQJ^JaJ/jh$?h:CJOJQJU^JaJ ho.h:CJOJQJ^JaJ4jh$?h:CJOJQJU^JaJmHnHu/j,h$?h:CJOJQJU^JaJ h$?h:CJOJQJ^JaJ)jh$?h:CJOJQJU^JaJ#ho.h:5CJOJQJ^JaJ 2 P   Roqr  $;Fҷң}vrvrvrvrniaia]V]V]V]V hD h~h~h%h~5 h%5hTh h0phTh%hT0J hT5 hb5hh%0h:CJOJQJ^J&ho.h:5>*CJOJQJ^JaJ4jh$?h:CJOJQJU^JaJmHnHu)jh$?h:CJOJQJU^JaJ/jh$?h:CJOJQJU^JaJ Fe"$&:<Xތ{cH4jh$?h:CJOJQJU^JaJmHnHu/jh$?h:CJOJQJU^JaJ h$?h:CJOJQJ^JaJ)jh$?h:CJOJQJU^JaJ hD h hD hD h,hD 5>*h0phD 5 hbhD hCC.h%hD 0Jh%hb0J h0phh~h%>*hb hD h~h~h%$&t %gdb  %]gdb$ %]a$gd(Agd%gd:gdCC.gd%]gdD $ %a$gd $ %a$gd%*24ptvƿꮖ{wwleWlF jh$?h:UmHnHujph$?h:U h$?h:jh$?h:UhCC.4jh$?h:CJOJQJU^JaJmHnHu/jh$?h:CJOJQJU^JaJ h$?h:CJOJQJ^JaJ hD hD hD hb h0ph h0ph:hCJOJQJ^JaJ)jh$?h:CJOJQJU^JaJ Ks44)4.474@4B4C4g4j44444444Żh )h^ h^h^ h^hCC. h^h(AU h0phbhCC.hb h~hb hCC.5 hb5h:hb5h0ph5 h0phh3Uh3Uh3U5 h5 h0ph:jh$?h:U1A4B4C44445K55555555\6]6^6~666 %4gd(A $ %a$gd^gd^ %gd(Agd^ %gdbuse or access is sought is necessary for your research purposes. ____________________________________ _____________________ Researcher Signature Date ------------------------------------------------------------------------------------------------------------ For CPHS USE ONLY CPHS Reviewer: ________________________ ------------------------------------------------------------------------------------------------------------ COMMENTS: COMMENTS FOR LETTER: [ ] Review Preparatory to Research [ ] IRB Review Required. Researcher is requested to complete a CPHS application for review. ADDITIONAL COMMENTS FOR LETTER: _______________________________________ ______________________ For the CPHS Date 44555#51525J555555556=6?6C6P6Z6[6]6~666666666ηγh h0phhThD h )h(Ah^h^h^0J h3U0Jh^h(A0J h%0J h0ph(Ah0ph(A5 666gd^21h:pb/ =!"#$% tDText1tDText1tDText2tDText1tDText1tDText1tDText1tDText1tDText1tDText1tDText1tDText1tDText1@@@ NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRiR  Table Normal4 l4a (k(No List4B@4  Body Text$a$2>@2 Title$a$5\JOJ ~ Title Char5CJ\_HaJmH sH tH 5 <9hij23&Gv !pq*>?!56 DEB C i      4 X  7 00000000000000000000000000000000000000000@00000000000000000000000000009ij2&Gvpq*?5     4 X  7 000000B00'xT^4w00@0@0@0@0@0@0@0@0@0J00J00@000 00 00 00 @0000000J0000 000"0 @00000000000R ^ F46 2 66 6 Q]cmy$3?Ebnt*6<!-35 FFFFFFFFFFFFF8@0(  B S  ?Text1Text2Q7 d7 @T@%!@d%!@+@\ @# *27  )1887 =*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType9*urn:schemas-microsoft-com:office:smarttagsplace _7  X q 7 333o6 i j } }     4 7 7 *;D CC.3UT: )b%~r(A^gjtq|=7 N@^cDc^^d^^^^^^Z 5 @@@ @ @@@@@(@@h@UnknownGz Times New Roman5Symbol3& z Arial"qhQcfQcf"Fc c !24/ / 2qHP)?28Dartmouth College " Dartmouth-Hitchcock Medical Center Ann O'Hara Ann O'HaraOh+'0, @L l x  <Dartmouth College Dartmouth-Hitchcock Medical Center Ann O'HaraNormal Ann O'Hara2Microsoft Office Word@F#@n>@D@Dc ՜.+,00 hp  Dartmouth College/ ' 9Dartmouth College Dartmouth-Hitchcock Medical Center Title  !"#$%&()*+,-./012345789:;<=?@ABCDEHRoot Entry F|DJData 1Table'WordDocument4<SummaryInformation(6DocumentSummaryInformation8>CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q