Per policy FH-COM.057, Froedtert Health entities are required to account for all use/disclosures of PHI for the purpose of research without patient authorization. Research Staff must complete and submit the accounting log below specific to that disclosure to FH HIM. Completed Logs will be considered valid for the length of the IRB Approval of the study. At time of government audit or other administrative request, researchers must be able to produce their less than 50 screening list within 48 business hours, if requested. For all research disclosures fill out the information below. Project Information Name of Research Protocol Do you have an IRB or PRO number? Yes, I can enter it now. The IRB or PRO number assignment is pending. No, there will never be an IRB or PRO number for this. IRB Number Principal Investigator (PI) Study Primary Contact Person E-mail To be used for confirmation of this form submission. Disclosure Timeframe This should reflect the timeframe from which your data will come – the timeframe that you have received IRB approval to access the PHI. From Date must be entered as MM/DD/YYYY. To Date must be entered as MM/DD/YYYY. Project Specifics Purpose of the Study Is the project screening LESS THAN 50 records? Note: Lists of less than 50 subjects screened are to be retained by the researcher. Yes No Type of PHI Sought Entire medical record Inpatient records Outpatient records Emergency Department records Progress notes Operative reports Discharge summaries Pathology report(s) Lab report(s) Images (X-ray, CT, MRI, etc.) EKG/Echo Other… Enter other… This log reflects information from Froedtert Hospital Froedtert Menomonee Falls Hospital Froedtert West Bend Hospital Froedtert & MCW Community Physicians CAPTCHA Save Draft Submit Leave this field blank Contact Us 414-805-4082 Contact Us MCW Office of Research MCW Human Research Operations Committee Office Location Froedtert Hospital Campus 9200 W Wisconsin Ave Milwaukee, WI 53226 Pavilion Building, 3rd floor Research For Researchers (OCRICC) Clinical Research Billing Compliance Requesting Froedtert Health Pricing Research Pricing Request Application Research Chargemaster Requesting OCRICC Administrative Approval Administrative Approval Request Application Operational Feasibility Planning Tool Research Consent Post-Approval Activities Use of Froedtert Health PHI PHI Accounting Log Contact Us Issue Escalation
