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Neuroimaging following TBI in non deployed setting

Form/Template
7/8/2013

The guidance contained in this CR represents a review of currently published literature and expert contributions obtained by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) in collaboration with clinical subject matter experts representing the Services, Department of Veterans Affairs (VA), academic, research and civilian sectors.

Recommended Content:

Health Readiness & Combat Support | Public Health | Disability Evaluation | Traumatic Brain Injury Center of Excellence

Cosmetic Surgery Superbill 2013

Form/Template
7/1/2013

Use this form to bill for cosmetic surgery.

DCoE Concussion Management Algorithm Cards

Form/Template
10/8/2012

Combat Medic/Corpsman Algorithm Card to diagnose a concussion in a deployed setting

Recommended Content:

Public Health | Disability Evaluation | Traumatic Brain Injury Center of Excellence | Health Readiness & Combat Support

Principal Investigator Certification

Form/Template
8/1/2012

Use this form if a Research Authorization Review template and an Authorization are approved by the DHA Privacy Board, a Principal Investigator (PI) will be required to sign a Principal Investigator Certification. Among other requirements, the certification ensures that the PI will maintain, electronically and/or in hard copy, the signed Authorization for each research participant whose PHI is used or disclosed in the project, and will provide any and/or all of the signed Authorizations to DHA immediately upon request.

Recommended Content:

Privacy Board

DHA Privacy Board Application for a Waiver of Authorization or an Altered Authorization

Form/Template
8/1/2012

Use this form if the researcher has not received documentation from an Institutional Review Board (IRB) or HIPAA Privacy Board approving a waiver or alteration of Authorizations and reasons exist that make it impractical or impossible for the researcher to obtain Authorizations from each research participant, the PI may submit an Application for a Waiver of Authorization or an Altered Authorization. A DHA Privacy Board member will conduct an expedited review of the completed application and determine whether to approve or deny an altered Authorization or a full or partial waiver of Authorizations.

Recommended Content:

Privacy Board

Research Authorization Review

Form/Template
8/1/2012

Use this form if the researcher intends to obtain HIPAA Authorizations, also known as “Authorizations,” from research participants to comply with the HIPAA Privacy Rule, the PI must submit to the DHA Privacy Board a copy of the blank Authorization(s) to be used in the project and the completed Research Authorization Review. The DHA Privacy Board will conduct a review to determine that all core elements and required statements are provided in the Authorization(s) as required by the HIPAA Privacy Rule and DOD 6025.18-R.

Recommended Content:

Privacy Board

Required Representations for Research on Decedents Information

Form/Template
8/1/2012

Use this form if the researcher intends to conduct research that is solely on the protected health information (PHI) of decedents, the PI may submit this template to document the required representations, as outlined above, that are necessary for compliance with the HIPAA Privacy Rule and Department of Defense (DOD) Health Information Privacy Regulation (DOD 6025.18-R).

Recommended Content:

Privacy Board

Required Representations for Review Preparatory to Research

Form/Template
8/1/2012

Use this form if the researcher intends to conduct a review of PHI to prepare for a research protocol or for similar purposes preparatory to research (e.g., for recruitment or screening purposes) and agrees not to remove the PHI from DHA, the PI may submit this template to document the required representations, as outlined above, that are necessary for compliance with the HIPAA Privacy Rule and DOD 6025.18-R.

Recommended Content:

Privacy Board

Request for Mitochondrial DNA Sequence Report

Form/Template
2/1/2012

Use this form to request a copy of your mitochondrial DNA type to help recover family member remains.

Brand over Generic Prior Authorization Form

Form/Template
8/10/2011

This form should be completed and signed by the prescriber to request prior authorization to use a brand name drug instead of a generic equivalent.

Individual Investigator Agreement

Form/Template
3/29/2011

This form is a tool that can be used when a collaborating investigator is not part of an institution with a federal assurance.

Disposition of Organs Retained for Extended Examination

Form/Template
3/8/2011

Use this form to grant permission to the Armed Forces Medical Examiner System to retain organs for an extended examination to determine cause of death.

Institutional Agreement for IRB Review

Form/Template
8/30/2010

This form should be used when an institution will be engaged in human subject research and will use an Institutional Review Board (IRB) that is not organizationally or legally part of the institution.

Supplemental Health Care Program Worksheet

Form/Template
4/16/2010

Use this worksheet when referring a service member under the Supplemental Health Care Program.

DOD Addendum to the Department of Health and Human Services Federalwide Assurance for the Protection of Human Subjects

Form/Template
8/20/2009

This form is a tool to help Institutions with an existing FWA approved by DHHS to know about and acknowledge key DOD policies and requirements since the DHHS FWA does not identify DOD requirements.

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Last Updated: October 18, 2022
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