IRB HIPAA Forms

As of March 1, 2016, all new applications, modifications, renewals, reportable new information and other work must be submitted to the HSPP via Click IRB. Visit the Click IRB Resources page for additional information.

HIPAA: Standalone Document for Reliance

• Standalone HIPAA for Reliance – revised July 2021 (DOCX)
  • Also available in the following languages:
    • Traditional Chinese (DOCX) – revised July 2021
    • Simplified Chinese (DOCX) – revised July 2021
    • Korean (DOCX) – revised July 2021
    • Russian (DOCX) – revised July 2021
    • Somali (DOCX) – revised July 2021
    • Spanish (DOCX) – revised July 2021
    • Vietnamese (DOCX) – revised July 2021

Legacy IRB HIPAA Forms

• HIPAA Authorization Form: Permission to Use, Create and Share Health Information for Research – revised April 11, 2013 (DOC)
  • Also available in the following languages:
    • Traditional Chinese (PDF) – revised April 11, 2013
    • Simplified Chinese (PDF) – revised April 11, 2013
    • Hindi (PDF) – revised April 11, 2013
    • Hmong (PDF) – revised April 11, 2013
    • Italian (PDF) – revised April 11, 2013
    • Korean (PDF) – revised April 11, 2013
    • Russian (PDF) – revised April 11, 2013
    • Somali (PDF) – revised April 11, 2013
    • Spanish (PDF) – revised April 11, 2013
    • Vietnamese (PDF) – revised April 11, 2013

• Like the English HIPAA forms, these translations should not be altered, except where allowed by the form itself. Study teams should use English to fill in any editable fields (any language other than English requires Certification of Translation).
• If the study team needs to use the "other" field in the PHI section and/or if English is not used in other editable sections, then the form must be certified translated.
• For the languages available on the website, study teams should use these certified translations because they contain English prompts.
• This form is used in addition to the research study consent form. The form contains all the elements needed to be compliant with the federal privacy rule known as HIPAA.

• Printable Research Disclosure Tracking Form (PDF) (for use outside Seattle Children's network)
  • Use this form when a Seattle Children's patient's health information (PHI) is accessed electronically (e.g., CIS, Invision, department databases) for use in an IRB-approved research study, where use of the information has not been authorized by the patient/parent (IRB approved a waiver of authorization) and when the research team contains members who are not part of Seattle Children's workforce.
  • Employees of Seattle Children's and CUMG, and residents and fellows working at Seattle Children's, are part of Seattle Children's workforce.
  • Your data will be automatically fed into Seattle Children's disclosure tracking system when you enter it into the electronic Research Disclosure Tracking Form. Seattle Children's must track all disclosures of PHI that were made without an authorization.