This form will send email to the IRB Review Committee.

This request should be submitted if you intend to view potential subjects' Protected Health Information before submitting a protocol to the IRB. This service can only be used if you will not be sharing any of this information outside the U of C prior to submitting a protocol. Once you have obtained enough information to justify your planned study, please submit a full protocol proposal to the IRB.

From: 

Contact:
Name: 
Email: 

Principal Investigator:
Name: 
Email: 
Unique ID:   help with unique ID

I hereby certify the following [check each box to certify]:

The use of protected health information ("PHI"- any information that might identify someone either directly or indirectly or could reasonable be used to identify an individual) is solely to prepare a research protocol.

The research will not involve recording or removing the PHI from the University of Chicago or the University of Chicago Hospitals.

The PHI requested is necessary for the purposes of the research.