Adventist HealthCare
Adventist HealthCare Institutional Review Board
Honest Broker Certification Form
IRB Study #: Organizational Entity:
Study Name:
Principal Investigator (PI):
Form Completed by:
|An Honest Broker is an individual, organization or system acting for, or on behalf of, the covered entity to collect and provide health information to |
|research investigators in such a manner whereby it would not be reasonably possible for the investigators or others to identify the corresponding |
|patients-subjects directly or indirectly. Individuals serving as an honest broker must be completely independent of the research team. |
|By signing below, I agree/certify that: |
| |
|1. I have reviewed this project with the Principal Investigator and agree to de-identify or code any data and/or specimens that will subsequently be used |
|in this protocol. |
| |
|2. I will, under no circumstance, provide the Principal Investigator or any member of the research team with identifying information about the subjects, |
|information that would permit the re-identification of research subjects, or the key to the code (as applicable). |
| |
|3. I will not commence any research activities for this project until proof of IRB approval or an IRB Determination has been provided to me by the |
|Principal Investigator. |
| |
|4. I will not intervene or interact with human subjects during the conduct of this research project. |
| |
|5. I will maintain the confidentiality of research subjects’ identifiable information, records or specimens. |
| |
|6. Once this project is complete I will destroy or return any identifiable information in my custody to its source and destroy the key to the code. |
| |
|7. I will immediately inform the AHC IRB Office of any breaches to this agreement by calling 301-315-3400. |
| |
|Honest Broker Name: |
| |
|Position: |
| |
|Email: |
|Telephone: |
| |
| |
|Supervisor of Honest Broker: |
| |
| |
| |
|SIGNATURE |
| |
|_________________________________________________ _____ |
|Signature of Honest Broker Date |
|By signing below, I agree/certify that: |
| |
|1. I will, under no circumstance, ask the Honest Broker to reveal identifying information of the research subjects from whom the specimens or data |
|originated, or the key-code linking the information. I will not otherwise seek out the identifying information about whom the specimens or data |
|originated. The same standards will be explained to, and expected of, my research team. |
| |
|2. I will submit any revisions to this activity to the AHC IRB for approval prior to implementing any changes. |
| |
|3. I will immediately inform the AHC IRB Office of any breaches to this agreement by calling 301-315-3281. |
| |
|SIGNATURE |
| |
|_________________________________________________ _____ |
|Signature of the Principal Investigator Date |
Addendum
|Date: |
|Revision to this project: |
| |
|Honest Broker Name: |
| |
|Position: |
| |
|Email: |
|Telephone: |
| |
| |
|Supervisor of Honest Broker: |
| |
| |
|SIGNATURE |
| |
|_________________________________________________ _____ |
|Signature of Honest Broker Date |
| |
|SIGNATURE |
| |
|_________________________________________________ _____ |
|Signature of the Principal Investigator Date |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- adventist healthcare jobs
- adventist healthcare jobs maryland
- adventist healthcare email outlook
- adventist healthcare jobs rockville md
- adventist healthcare careers
- adventist healthcare outlook email
- adventist healthcare rockville
- adventist healthcare email
- adventist healthcare professional
- adventist healthcare professionals intranet
- adventist healthcare professionals outlook
- adventist healthcare hospital locations