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

Do you have an IRB or PRO number?
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.
Date must be entered as MM/DD/YYYY.
Date must be entered as MM/DD/YYYY.

Project Specifics

Is the project screening LESS THAN 50 records?
Note: Lists of less than 50 subjects screened are to be retained by the researcher.
Type of PHI Sought
This log reflects information from
Enter the characters shown in the image.
Get new captcha!
Share This: