Supplemental Forms for Researchers

Download and complete the following forms to submit with your online application.

Collaborator Endorsement Letter

Collaboration Endorsement Letter Template: required when an investigator relies on UnityPoint Health – Meriter staff to aid their research in some way. The letter spells out in what ways the collaborating person/department will help the researcher. The letter should be signed by a department or work area manager, director or other authority.

Examples of research collaboration carried out by non-research staff:

• Handing out recruitment materials.
• Passing information such as consent to contact forms from prospective subjects to the investigator.
• Keeping recruitment brochures and flyers available in waiting or examining areas.
• De-identifying and/or coding a bio-specimen and temporarily storing it until research staff can pick it up.

Consent Document

Consent Template: Customize by adding or deleting text as it applies to your research. Please do not delete text that is mandatory.

Consent Template Customize by adding or deleting text as it applies to your research. Please do not delete text that is mandatory. 

Consent Checklist for IRB Reviewers.

HIPAA Research Forms

• Which HIPPA Requirement?
• HIPAA Authorization Form (Word 2016)

Research Posted on UnityPoint.org

Research Listing: Complete this form if your research has a consent document. This form is not required for record review or biospecimen research.

Record Review Research Forms

• Patient Records Endorsement Form: mandatory for record review research. 
• Electronic Data Security Endorsement: mandatory when identified electronic data is being transferred or stored. 
• Data Research Summary Form: mandatory for most record review research.