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.

HIPAA Research Forms

• Which HIPPA Requirement?
• HIPAA Authorization Form (Word 2010)
• HIPAA Authorization Form (Word 2010) for Meriter Researchers requesting a deferral to Western IRB.

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.
• External Access Request