ࡱ> .0/@ bjbjFF *,,WSTTTd8 244JJJ) ) ) $R)W % ) W W )JJ>W W W W "JJW W W W :C,J( 0 y o T0yR t$) Lu 6W , ) ) ) ))A SAINT LOUIS UNIVERSITY HIPAA DE-IDENTIFICATION CERTIFICATION FORM PI Name ______________________________ IRB Protocol # _______________________ Project Title: ___________________________________________________________________ Research that involves the use of de-identified protected health information (PHI)( is exempt from HIPAA requirements. To be exempt from HIPAA, none of the following subject identifiers can be recorded by the research team. Names (individual, employer, relatives, etc.) Address (street, city, county, zip code initial 3 digits if geographic unit contains less than 20K people, or any other geographical codes) Telephone/Fax Numbers Social Security Numbers Dates (except for years) directly related to an individual. For example: Birth Date Admission Date Discharge Date Date of Death Ages >89 and all elements of dates indicative of such age (except that such age and elements may be aggregated into a category Age>90 E-mail Addresses/URLs Medical Record Numbers Health Plan Beneficiary Numbers Account Numbers Certificate/License Numbers Vehicle Identifiers and Serial Numbers (e.g. VINs, License Plate Numbers) Device Identifiers and Serial Numbers Biometric Identifiers (e.g. finger or voice prints or full face photographic images) Any other unique identifying number, characteristic, or code I certify the protected health information (PHI)( received or recorded by research personnel for the research project referenced above does not include any of the 18 identifiers listed above Principal Investigator Signature: ________________________________ Date: ______________ ( PHI: individually identifiable health information transmitted or maintained in any form (electronic means, on paper, or through oral communication) that relates to the past, present or future physical or mental health or conditions of an individual. July 7, 2003 Rev 2/4/05  FILENAME HIPAA_De-identification_Certification_Form = > | l m VWXYRTUnoyzh+CJmHnHuh^CJmHnHujh^CJU h^CJ j*h^0J h9gCJh^ j*h9g0J h9g>*h9gCDE   * 8  9 v%v%v%v%v%v%v%v%\2v%v%Hv%Ճv%Hv%Hv%Hv%v%v%v%v%v%Hv%Hv%Hv%Hv%Hv%Hv%H & F & F & F$a$WU ; < WSTUbv%Hv%Hv%v%΅v%v%v%v%(v%v:v%^v%^v%$a$ & F(PP&P/ =!-"-#$%<@< NormalCJ_HmH sH tH DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List 6>@6 Title$a$ 5CJ\:@:  Footnote TextCJ@&@@ Footnote ReferenceH*4@"4 Header  !4 @24 Footer  !=l zCDE *8 9;<WSTUb000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000000\>0800\>0\>0RRRU   $OU8@0(  B S  ?]|]L]<]] Uf al=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType9*urn:schemas-microsoft-com:office:smarttagsplace8*urn:schemas-microsoft-com:office:smarttagsdate 22003200547DayMonthYearfjWUWUDDl89nv|VWUWUEczP2cz hh^h`OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( Q Q ^Q `OJQJo(o ! ! ^! `OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo( hh^h`OJQJo( ^`OJQJo(o^`QJo(- ^`OJQJo( Q Q ^Q `OJQJo(o ! ! ^! `OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo(EP2Fמ        מ J      ^9g+WR@H@UnknownGz Times New Roman5Symbol3& z Arial?5 z Courier New;Wingdings"qh,#,#;w&e e !r4TT3QH(?9g*HIPAA DE-IDENTIFICATION CERTIFICATION FORMResearchjostnl  Oh+'0  ,8 T ` l x+HIPAA DE-IDENTIFICATION CERTIFICATION FORMoIPA ResearchIDEeseeseNormalhjostnlh2stMicrosoft Word 10.0@F#@~dD@X} @X} e՜.+,D՜.+,l( hp  University of Kentucky TA +HIPAA DE-IDENTIFICATION CERTIFICATION FORM TitleH@$<_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_ReviewingToolsShownOncek's#Change the de-identification form OJoe.Brown@uky.eduti Brown, Joe R.edrow  "#$%&'(+Root Entry F͎ -1Table WordDocument*SummaryInformation(DocumentSummaryInformation8!CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89qRoot Entry F9 31Table WordDocument*SummaryInformation(  21 (Pp_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_ReviewingToolsShownOnce_PreviousAdHocReviewCycleIDoIRB Web updatejostnl@slu.edu Nancy Jostk'sDocumentSummaryInformation8CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q՜.+,D՜.+,l( hp  University of Kentucky TA +HIPAA DE-IDENTIFICATION CERTIFICATION FORM Titlex@