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: |

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|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. |

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|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). |

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|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. |

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|4. I will not intervene or interact with human subjects during the conduct of this research project. |

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|5. I will maintain the confidentiality of research subjects’ identifiable information, records or specimens. |

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|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. |

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|7. I will immediately inform the AHC IRB Office of any breaches to this agreement by calling 301-315-3400. |

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|Honest Broker Name:       |

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|Position:       |

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|Email:       |

|Telephone:       |

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|Supervisor of Honest Broker:       |

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|SIGNATURE |

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|_________________________________________________ _____ |

|Signature of Honest Broker Date |

|By signing below, I agree/certify that: |

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|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. |

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|2. I will submit any revisions to this activity to the AHC IRB for approval prior to implementing any changes. |

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|3. I will immediately inform the AHC IRB Office of any breaches to this agreement by calling 301-315-3281. |

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|SIGNATURE |

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|_________________________________________________ _____ |

|Signature of the Principal Investigator Date |

Addendum

|Date:       |

|Revision to this project:       |

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|Honest Broker Name:       |

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|Position:       |

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|Email:       |

|Telephone:       |

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|Supervisor of Honest Broker:       |

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|SIGNATURE |

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|_________________________________________________ _____ |

|Signature of Honest Broker Date |

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|SIGNATURE |

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|_________________________________________________ _____ |

|Signature of the Principal Investigator Date |

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