Forms & Template

Go to PRISM 

Affiliate Investigator Instructions

Authorization Agreement

Consent Form Template 

Form of Notice By IND/IDE Holder

MRI Director Approval

Notice of Privacy Practices

Protocol Violation Form

Uploaded Protocol Summary Form (PSF)

 

Unanticipated Problems/SAE Form

Reliance Request Form (request to have the NYSPI IRB rely on another IRB which serves as the IRB of Record)

Research Monitoring Form  

Request for Use of De-Identified Data

Short Form for Witness of Consent (to be used for non-English speaking participants or participants who cannot read)

For technical questions, click here....

 

HIPAA Forms

HIPAA Authorization  

HIPAA Child Authorization

HIPAA Waiver

 HIPAA Authorization (Spanish)

 HIPAA Child Authorization (Spanish)

 

PLEASE NOTE, a fillable HIPAA form is available on the NSYPI Intranet. To access the NYSPI Intranet, please go to the NYPSI.org site, then For Employees and Staff. The left column menu bar offers NYSPI Intranet. Once you are on the NYSPI Intranet site, the right column Quick Links offers HIPAA. On the HIPAA page, the right column the third bullet point under HIPAA/Privacy Rescources links to the fillable form.

Patient Chosen Surrogate (PCS) Forms

PCS Checklist

PCS Form III(a) 

PCS Form IV

 PCS Form I    

 PCS Form III(b)  

 

 PCS Form II

 PCS Form III(c)

 

 

Spanish PCS Form II  

Spanish PCS Form III (b) 

Spanish PCS Form IV

  Spanish PCS Form III (a)

  Spanish PCS Form III (c)

 

 

PCS Policy Letter to MHLS  

 

NYSPI IRB Guidance Documents

Revised Common Rule 2019

Multi-Site Protocols 2016

Gadolinium Guidance 2016

 

Policy of Women of Childbearing Potential

Alternative Lay Language for Medical Terms

MRI Guidelines