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Home : About Meriter : Clinical Research : Supplemental Forms for Researchers

Supplemental Forms for Researchers

Log on to Meriter IRB Online Application Site

IRB Application Coaching

One on one in person or over the phone. Use contact information below to make an appointment.

Meriter IRB Office
202 South Park Street
Madison, WI 53715

Liz Michaels, MS, CIP
IRB Coordinator
lmichaels@meriter.com
 
Office: (608) 417-6411
Fax: (608) 417-5675

Office Located on Meriter Hospital Campus
229 McConnell

Map & Directions to IRB Office

Download and complete the following forms to submit with your online application.
 
Consent Template

Customize this template by adding or deleting text as it applies to your research. Please do not delete text that is mandatory.
  

HIPAA Authorization Form
Use this form if you will be looking at and recording private health information that is identifiable. Most of the time you will need a HIPAA Authorization form if you are also using a consent document.


Waiver of HIPAA Authorization Form
Use this form if you will not be recording private health information. For example, medical record research where none of the 18 HIPAA identifiers are recorded.

Instructions for Waiver of HIPAA Authorization


Which HIPAA Requirement?
     

Research Listing for Meriter.com
Required for research where the investigator interacts with the subjects. Not required for record research or biospecimen research.
  

Record Review Research Forms


Patient Records Endorsement Form
Use this form to gain permission from the appropriate authority to access patient records for research purposes. Mandatory for Record Review Research.
 
Electronic Data Security Endorsement
Use this form if you had the Meriter IS Security Analyst set up a secure account for saving identified data. Mandatory for electronic record review research.
    

UW Deferral Forms

Download, print and have the Principal Investigator sign off on theses completed forms. Scan the forms into your computer and attach them to your online deferral submission.