IRB Forms | UnityPoint Health - Des Moines

UnityPoint Clinic Urgent Care - Altoona

00 Patients
Waiting Now

UnityPoint Clinic Urgent Care - Ingersoll

00 Patients
Waiting Now

Urgent Care - Ankeny

01 Patients
Waiting Now

Urgent Care - Lakeview

00 Patients
Waiting Now

Urgent Care - Merle Hay

03 Patients
Waiting Now

Urgent Care - Southglen

02 Patients
Waiting Now

Urgent Care - Urbandale

01 Patients
Waiting Now
UnityPoint Health - Des Moines


Forms are modified frequently to correct errors and clarify points. Check this page often to ensure you are using the latest version of the IRB forms.

New Study Applications - Local IRB Review

All new local studies must accompany the IRB Application for New Protocol, an informed consent OR a Request for Waiver of Informed Consent, Study protocol, COI forms and human subjects training certificates for every person listed on the study application. The IRB Coordinator will not process the materials for final review until all items are received and complete.

Application For New Protocol (5/2018)

Application for New Chart Review Protocol (5/2018)

Informed Consent Template  (5/2018)

Application to Review PHI in Preparation of Research (5/2018) 

Request for Waiver/Documentation of Informed Consent  (5/2018)

Example of Simple Protocol (5/2018) - to be used for non drug/device studies

IRB Conflict of Interest Form (2018-2019) 

CITI Human Subjects Training (See Education Tab)

When logging in for the first time, click the "Register" button in the top right hand corner of the home page. Under "Select an Organization Affiliation", start typing "UnityPoint" and "UnityPoint Health Des Moines should populate. Continue to register your account.

Which modules do I complete?

Biomedical Modules:  Select this option if you are involved in biomedical research study where an intervention is being conducted (drug, device, labs, medical testing), or consent human subjects. There are 9 required modules to complete.

Social-Behavioral-Educational Modules - Select this option if you are involved in non-intervention studies, such as retrospective chart reviews, surveys, etc. More than likely, if you are requesting a waiver of informed consent, you can complete these modules. There are 9 required modules to complete.

You must complete the "Required Modules". There are several "Optional Modules" that you may complete, but they are not required to conduct human subjects research.

New Study Applications - Central IRB Notification

The CIRB Application is to be used when an external Central IRB is overseeing the research. Examples of an external Central IRB would be Western IRB, Quorum, etc. Please Note: Whenever a study will utilize hospital departments, such as lab, radiology, etc., you must follow the Central IRB Notification Process outlined in the HRPP Procedures (Sections O & P)

For additional information regarding CIRB studies, please refer to the HRPP Procedures, Sections O & P. 

Revisions/Amendments to Previously Approved Studies

Use this form when you have to make a change to a previously approved protocol. Please submit a separate sheet of paper to explain the changes you wish to make to the study.

Request for Revision/Amendment (5/2018)


Study Closure Forms                                                                                             

Local Enrollment Closure Report (5/2018) - This form is to used when study subjects are no longer being enrolled in a study.

Final Study Closure Report (6/2018)   - This form is to be used when all study activity and data analysis has ceased and the study can be closed with the local IRB.  No research related work can be conducted after this form is submitted for final closure.


Unanticipated Problems & Protocol Deviations

Any unanticipated problem that is serious, unexpected and related to the research drug or intervention must be reported to the IRB within 7 working days of the investigator learning of the event.

24 Hour Serious Adverse Event (SAE) Notification  (5/2018) - This form is to be used for all serious adverse events that occur with a study subject (i.e. hospitalization, life threatening event, death). Please refer to the form for additional information on reporting of SAEs.

Non-Compliance Report Form  (5/2018) - This form is to be used for events that are unforeseen, related to the research  and indicate that participants or others are at increased risk of harm. This form is to be used for both internal and external events, as well as protocol deviations and violations. All events reported will be reviewed by the full convened IRB.

Internal events are events that occur within our institution.

External events are events that occur at another institution where the study is occurring.  

A protocol violation is an accidental or unintentional change to the IRB approved protocol, that harmed participants or others that indicate participants or others may be at increased risk or harm.

A protocol deviation is an abnormality with a particular study that occurs with such frequency that this may have an adverse effect on the risk/benefit analysis of the study.


Emergency Investigational Drug/Device/Biologic Use Form    

Emergency Use IRB Form  (8/2015)  

Emergent Use Consent Template  (2/2015)

List of Previously Approved Emergent Use Drugs/Devices (2/25/15)

Hospital Policy UPHDM177 - Emergency Use of Experimental Drugs and Devices 


Other Forms
Pharmacy Services Utilization Form

Child Assent Template   (4/2014)

Child's Assent - Patient Participant Statement Template  (4/2014)

Sample Non-English Speaking Consent Form