ࡱ> 9 Gbjbj ehhKav v $,,,P|4,2&Lx(| @1111111$47 2uIII 2~2E%E%E%IF1E%I1E%E%rG/TG0 /1202/`8A|`8G0G0`8[0tIIE%IIIII 2 2!III2IIII`8IIIIIIIIIv X :  WSU Research Accounting of Disclosures Form Guidance and Instructions The Privacy Rule (HIPAA) requires that researchers account for all disclosures that they make of protected health information (PHI) that has been obtained under a waiver of authorization by the WSU IRB or another WSU IRB of Record that involves research on decedents where no authorization on behalf of the individual has been obtained. A disclosure is sharing PHI with an individual or institution outside WSU covered functions. Use means to employ, apply, utilize, examine, or analyze PHI maintained within WSU covered functions. Accounting is required for certain disclosures, not for use of PHI. Please complete this form and submit it to the HIPAA & Privacy Compliance Officer at: HYPERLINK "mailto:%20jj.jenkins@wright.edu"jj.jenkins@wright.edu. Part I Name individual submitting form:  FORMTEXT       Date form submitted:  FORMTEXT       Check the appropriate box to indicate the type of research covered by this accounting:  FORMCHECKBOX  Human subject research conducted under waiver of authorization granted by IRB of Record IRB Name:  FORMTEXT       IRB#:  FORMTEXT       Study Title:  FORMTEXT        FORMCHECKBOX  Research on Decedents Describe the activity in which the disclosure was made:  FORMTEXT       Part II Does your research involve disclosures for 50 or more individuals?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes only complete and submit Part III (page 1 and 2) of this form. If no only complete and submit Part IV (page 1 and 3) of this form. Part III Disclosures for 50+ Individuals Please answer all of the following questions. When completed, submit form to XXX. Name individual submitting form:  FORMTEXT       Date form submitted:  FORMTEXT       A description, in plain language, of the study, including the purpose of the study and the criteria for selecting particular records:  FORMTEXT       A brief description of the PHI to be disclosed:  FORMTEXT       The date or period of time during which such disclosures occurred, or may have occurred, including the date of the last such disclosure during the accounting period:  FORMTEXT       The name, address, and telephone number of the entity that sponsored the study and of the outside researchers to whom the PHI likely will be disclosed:  FORMTEXT       WSU investigators must provide the following Information if WSU receives a request for an accounting of disclosures made during the course of research: If WSU receives an appropriate request for an accounting of disclosures that were made relating to the individual over a given period of time (the accounting period), WSU Officials will ask the investigator to state, to the extent possible, the following: The date or period of time during which the disclosures in the study occurred, including the date of the last such disclosure during the accounting period. ,-.;GHI]`aij  ͻvivi\iO\\B5h.ph%cOJQJ^Jh.ph)OJQJ^Jh.ph#SOJQJ^Jh.phOJQJ^Jh.phyOJQJ^Jh.ph\OJQJ^Jh.ph5OJQJ^Jh.ph5OJQJ^Jh.phh{5OJQJ^Jh.phjQ25OJQJ^J#h.phy5CJ OJQJ^JaJ #h.phjQ25CJ OJQJ^JaJ #h.ph%c5CJ OJQJ^JaJ h.phy5OJQJ^J-.HI J K L S T   b f    h8@@@gd)  h8@@@gd)  h8@@@gd  h8@@@gd$ h8@@@a$gd h8@@@   2 ? 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These inquiries will be made to the investigator by WSU Officials after the receipt of the request for an accounting. WSU will need the investigator s answers to the above questions in order to provide the individual with the accounting. NOTE: If it is reasonably likely that the individual s PHI was disclosed during the study, WSU must, at the request of the individual, assist in contacting the entity that sponsored the study and the outside researchers. WSU Officials will ask for the investigator s help in providing this information to the individual. Part IV  Disclosures for < 50 Individuals Name individual submitting form:  FORMTEXT       Date form submitted:  FORMTEXT       IRB#, if applicable  FORMTEXT       A description, in plain language, of the study, including the purpose of the study and the criteria for selecting particular records:  FORMTEXT       The name, address, and telephone number of the entity and/or individuals that received the information:  FORMTEXT       Patient NameMedical Record NumberFirst Date of DisclosureLast Date of DisclosureFrequency of AccessDescription of Information Disclosed     Research Accounting of Disclosures: 09072016 Page  PAGE 3 of  NUMPAGES 3 >RATAVAXAAABBCCCDDD  h8@@@gd[n  h8@@@gdM}- h8@@@$d%d&d'dNOPQgd}5 h8@@@h$d%d&d'dNOPQ^h`gd%cXAfAjAAAAAAAAAABB B BBBBBBB"BLBNBbBdBfBhBjB񠶈wcwLL,jh.ph[nOJQJU^JmHnHu'jh.ph[nOJQJU^J!jh.ph[nOJQJU^J/jh.ph[n5OJQJU^JmHnHu*j h.ph[n5OJQJU^J$jh.ph[n5OJQJU^Jh.ph[nOJQJ^Jh.phHQ9OJQJ^Jh.phHQ95OJQJ^Jh.ph[n5OJQJ^JjBlBnBpBrBtBzB|BBBBBBBBBBBBBBBCCCC˾˱ˠˌuuuuugYLLLh.ph[nOJQJ^Jh.ph[n5OJQJ^Jh.ph[n6OJQJ^J,jh.phHQ9OJQJU^JmHnHu'jh.phHQ9OJQJU^J!jh.phHQ9OJQJU^Jh.ph|hOJQJ^Jh.ph%cOJQJ^Jh.phHQ9OJQJ^J!jh.ph[nOJQJU^J,jh.ph[nOJQJU^JmHnHuCCCCCCCCCCCCDjDDDDDDDDDDDDDDDDE@ErEEEFFFFFFF F"F$F&F(F*F,F.Fڶڶ{ڶ'j h.ph[nOJQJU^Jh.phsxOJQJ^Jh.ph|hOJQJ^Jh.phHQ9OJQJ^Jh.ph[nOJQJ^J,jh.ph[nOJQJU^JmHnHu!jh.ph[nOJQJU^J'ji h.ph[nOJQJU^J0DE@ErEEEFFFFFF F"F h8@@@$Ifgd,zFf $ h8@@@$Ifa$gd,z "F$Fkd $$Iflֈ |4(#L5 T$ t0644 lap<yt,z$F&F(F*F,F.F0F h8@@@$Ifgd,z.F0F2F4F6F8F:FF@FBFDFFFHFJFLFNFPFRFTFVFXFZF\F^F`FbFdFfFhFjFlFnFpFrFtFvFxFzF|F~FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFh.ph|hOJQJ^Jh.phHQ9OJQJ^J[0F2Fkd$$Iflֈ |4(#L5 T$ t0644 lap<yt,z2F4F6F8F:FF h8@@@$Ifgd,z>F@Fkd$$Iflֈ |4(#L5 T$ t0644 lap<yt,z@FBFDFFFHFJFLF h8@@@$Ifgd,zLFNFkd$$Iflֈ |4(#L5 T$ t0644 lap<yt,zNFPFRFTFVFXFZF h8@@@$Ifgd,zZF\Fkd$$Iflֈ |4(#L5 T$ t0644 lap<yt,z\F^F`FbFdFfFhF h8@@@$Ifgd,zhFjFkd$$Iflֈ |4(#L5 T$ t0644 lap<yt,zjFlFnFpFrFtFvF h8@@@$Ifgd,zvFxFkd$$Iflֈ |4(#L5 T$ t0644 lap<yt,zxFzF|F~FFFF h8@@@$Ifgd,zFFkd$$Iflֈ |4(#L5 T$ t0644 lap<yt,zFFFFFFF h8@@@$Ifgd,zFFkd$$Iflֈ |4(#L5 T$ t0644 lap<yt,zFFFFFFF h8@@@$Ifgd,zFFkd}$$Iflֈ |4(#L5 T$ t0644 lap<yt,zFFFFFFF h8@@@$Ifgd,zFFkdw$$Iflֈ |4(#L5 T$ t0644 lap<yt,zFFFFFFF h8@@@$Ifgd,zFFkdq$$Iflֈ |4(#L5 T$ t0644 lap<yt,zFFFFFFF h8@@@$Ifgd,zFFkdk$$Iflֈ |4(#L5 T$ t0644 lap<yt,zFFFFFFF h8@@@$Ifgd,zFFkde$$Iflֈ |4(#L5 T$ t0644 lap<yt,zFFFFFFF h8@@@$Ifgd,zFFFFFFFFFFFFFFGGGGG G GGGGVGZGdGlGnGpGzG|GGGGGGGGGGGGʺtth%c5\mHnHu h\5\jh\5U\h\h7;h.ph7;5CJOJQJ^Jh.phm5CJOJQJ^Jh.ph%c5CJOJQJ^Jh.phjQ25CJOJQJ^Jh.pjh.pUh.phHQ9OJQJ^Jh.ph|hOJQJ^J*FFkd_$$Iflֈ |4(#L5 T$ t0644 lap<yt,zFFFFFFF h8@@@$Ifgd,zFFkdY$$Iflֈ |4(#L5 T$ t0644 lap<yt,zFFFFGGG G GGGnGpGGGGGG$a$gd<_$a$gd<_$a$ h8@@@gd\ h8@@@  h8@@@gd[nGGGGGh.phHQ9OJQJ^Jh.ph7;#h<_h7;CJOJQJ^JaJh,1h/ =!"#`$% 51h0:p[n= /!"`#$% DyK yK Xmailto:%20jj.jenkins@wright.eduyX;H,]ą'ctDText4tDText5tDeCheck1vDText11tDText1tDText2tDeCheck2tDText3tDeCheck3tDeCheck4tDText4tDText5tDText6tDText7tDText8tDText9tDText4tDText5vDText10tDText6tDText9F$$If!vh#v #v#v#v#vT#v$:V l  t<065 5555T5$p<yt,zkdQ $$Iflֈ |4(#L5 T$  t<0644 lap<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,z$$If!vh#v #v#v#v#vT#v$:V l t065 5555T5$p<yt,zx02 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 4@4 Header  !4 @4 0Footer  !6U`6 Hyperlink >*B*ph.)!. <_ Page NumberH2H 8 Balloon TextCJOJQJ^JaJFV AF nmFollowedHyperlink >*B* phjSj HQ9 Table Grid7:V06/a6 \0 Footer CharCJaJ6/q6 ) Header CharCJaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y y$$. ;;`````````c K T f:XAjBC.FFGG %&'+FK b>D"$02>ܹFFFFFFFFFFFFFFFFF$()*,-./0123456789:;<=>?10<B"x (.5AGXFFtG$FtFtFtG$FtG$G$FFtFtFtFFFFtFtFtF@GINZ\c!8@0(  B S  ?Check1Text11Text1Text2Check2Text3Check3Check4Text4Text5Text6Text7Text8Text9Text10E1y  WC# /KMNPQSTVW1? 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PLP^P`LhH.Avg*s'Ny8         ~j]WVT-#m Z5*jQ2D68HQ9b<p'>}MAJ9D&FdGH J::K3%L#S(Z\ht]M}`WazRa%cXfnf|hnm[n.puAqkiqgbxlq0 x @!)S}XHC,z)r@AuI4P~v!,y-:%)m?MIh{M} }7;!_DBL*T:Njxsx<_5KM@JJJJp  @@@ @@ @@@@@0@@<Unknown G.[x Times New Roman5Symbol3. .[x Arial7..{$ Calibri5. .[`)TahomaC.,.{$ Calibri Light?= .Cx Courier New;WingdingsA$BCambria Math"ht;Ig G_lAg!`20CC 3Q@P?<_2!xx$ (MULTIPLE DISCLOSURES ABOUT AN INDIVIDUALCharlotte WyshamMcAllister, Whitney    Oh+'0 0< \ h t ,MULTIPLE DISCLOSURES ABOUT AN INDIVIDUALCharlotte Wysham Normal.dotmMcAllister, Whitney5Microsoft Office Word@캃@RN@z0 @}  ՜.+,D՜.+,X hp  HomeC )MULTIPLE DISCLOSURES ABOUT AN INDIVIDUAL Title 8@ _PID_HLINKSAx? mailto:%20jj.jenkins@wright.edu  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLNOPQRSTUVWXYZ[]^_`abcdefghijklmnopqrstuvwxz{|}~Root Entry FT Data MS1Table\|8WordDocumenteSummaryInformation(yDocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q