Sample Documents | Office of Research Compliance | SIU

Sample Forms and Documents

• Sample Consent Form - for Form C (no A/V recording) 
• Sample Consent Form - for Form C (with A/V recording) 
• Sample Consent Form - for Form D 
• Sample Guardian Consent Form - for Form D 
• Sample Cover Letter (Implied Consent) 
• Sample Telephone Script 
• Sample E-Mail Solicitation Request 

Health Insurance Portability and Accountability Act (HIPAA) Requirements:

New federal law has mandated changes in the procedures needed to access private health information. Researchers should contact the agency that owns the health records and ask them for the specific language that they require in consent forms before they will release subjects' health records. The consent form must identify what specific health care information will be collected from the files. Below is a link to a sample form, but most agencies will have their own requirements.

• Sample Language to Include in a Consent and Authorization Form