Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES F-82021 (07/08)

STATE OF WISCONSIN Wisconsin Statutes Chapter 19

RESEARCHER'S REQUEST FOR CONFIDENTIAL RECORDS OR HUMAN SUBJECTS RESEARCH
INSTRUCTIONS: 1. Fill out this form completely for research dealing with confidential records or human subjects. 2. If more than on person is conducting the research, this form should be completed by the principal researcher. 3. Feel free to add attachments if necessary and / or include any additional information you believe is relevant. 4. Depending upon the nature of the information supplied below, the Department may ask the research to supply additional information or assurances before making a final decision. Name ­ Researcher Agency / Organization Represented by Researcher (If Applicable)

Address (Street, City, State, Zip Code)

Telephone Number

Project Title (If Any)

Identify the confidential records being requested

On a separate attachment, describe the purpose of your research and how you intend to use the requested records. At a minimum, the following must be included: 1. The purpose of your research, the significance of this research and the relationship of this research to other research. For research involving "human subjects", the following information will need to be provided: a. b. c. d. Specify the sample to be studied: (age, sex, location, etc.) Specify the number of cases in the study and how the sample is selected. When will the data be gathered? How will the information be obtained? (i.e., interview, existing data, questionnaire, standardized test, etc. Attach two copies of all tests and / or rating schedules to be used.)

2. 3. 4. 5. 6.

The particular procedures you intend to follow in examining and in analyzing the data. To whom you will disclose the confidential record information. The type of reported to be prepared. To whom your reports will be disseminated. Projected timeframe / deadlines.

F-82021 ­ Page 2 Describe your employment, academic or other background pertinent to the research; indicate the name(s) and affiliation(s) of any person(s) supervising your project; and describe the background of the supervisor. List names of any other people not already mentioned who will participate in conducting the research.

Assurances (Indicate your response by checking the appropriate box.) Yes No 1. Do you agree not to report this information in any way that identifies or could lead to the identification of individuals or otherwise violates confidentiality requirements? Do you agree to collect and use the information contained in these records only in the manner described in this request and attachments, subject to any penalties imposed by law? Do you agree not to reproduce these records or remove them from the Department without express permission from the Department? Do you agree to provide the Department with copy(s) of your report? There may be costs involved in retrieving these records. Do you agree to pay for the actual costs incurred by the Department in retrieving these records? (A cost estimate will be provided upon request.)

Yes

No

2.

Yes

No

3.

Yes Yes

No No

4. 5.

Please be advised that if your request is granted, any release of information contrary to the assurances above could result in penalties imposed by law and any violation of any of the above assurances will result in termination of DHS's participation in the research project.

SIGNATURE ­ Researcher

Title

Date Signed

Division Name

FOR DEPARTMENT USE ONLY (This form is to be processed pursuant to AD-50.) Bureau / Office RECORD CUSTODIAN DECISION SIGNATURE ­ Record Custodian

DECISION Grant Request Deny Request RECOMMENDATION Grant Request Deny Request DECISION Grant Request Deny Request

Date Signed

PROGRAM OR HUMAN SUBJECTS REVIEW BOARD DECISION SIGNATURE ­ Person Investigating Request

Date Signed

SIGNATURE ­ Designated Decision-Maker or Human Subjects Board Representative

Date Signed