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THE HUMAN RESEARCH PROTECTION PROGRAM

THE COMMITTEE ON HUMAN RESEARCH

UCSF CHR HIPAA DECISION TREE

FOR BEFORE AND AFTER APRIL 14, 2003

Decision Tree

Background:
 
  Does research use PHI?
  NO, if none of the 18 protected health identifiers are created, used, or disclosed in the course of providing a health care service.
  THEN
    HIPAA does not apply
    Submit CHR application as usual
    Include HIPAA Supplement with Application
  Does research use PHI?
  YES, if any of the 18 protected health identifiers are created, used, or disclosed in the course of providing a health care service.
  THEN, if study was approved before April 14, 2003:
    Continue CHR-approved study until time of next renewal or until requesting consent modification.

    Use currently approved consent (if any).
    Any new subjects enrolled April 14, 2003 or after will have to sign a Subject Authorization in addition to consent form (PI keeps until study is ended).
    Consent/Authorization plan will be revisited by CHR at renewal time.
    Note: The CHR does not need to review the Subject Authorization as long as the standard UCSF (Spanish Version: UCSF Subject Authorization for Release of PHI for Research)or VAMC Authorization is used. All other versions require review by the CHR and their use will result in a delay of approval.
  THEN, if study was approved April 14, 2003 or after:
    If using full or expedited committee application,
      Submit HIPAA Supplement
      Submit separate Subject Authorization (Spanish Version: UCSF Subject Authorization for Release of PHI for Research) (strongly recommended)–or- consent form with HIPAA language embedded and/or
      If waiver is requested (for screening, recruitment or conduct of study), submit Waiver of Consent/Authorization Supplement
    If modifying a study, then above applies unless no changes are made
      to screening or recruitment procedures or to conduct of study or
      to consent documents.
    If using a limited data set, submit expedited application.