Veteran Information Access Agreement Form

Fill out this form for UCSF research projects of which SFVAHCS is only an administrative site. SFVA is considered an administrative site, when local va resources such as SFVAHCS property, office, computer, server or email are used, and/or time goes, but: For a common DOD/VA study: active military personnel are recruited to enroll in VA research and there are agreements for all injuries related to the search for va to be treated by active staff enrolled in this protocol (hospitalization or outpatient). In the event that an active duty officer is in a VA medical facility where emergency medical assistance is required, emergency treatment is performed within the VA until the subject is stabilized and the active staff member is transferred to the nearest medical facility to the DOD, capable of treating the injury/problem. VA HIPAA (Authorization for Use – Release of Protected Health Information for Research Form 10-0493): Consideration should be given to reducing the risk of COVID 19 transmission to researchers and researchers as much as possible. Remote study procedures can and should be used if possible. This may include, among other things, obtaining remote consent, remote study visits and/or the use of web surveys or mobile applications for data collection. More information can be found in the guides below and on the CDC website for covid-19 updates. VA Investigational Drug Information Report (10-9012) The Veterans Affairs Request for and Authorization to Release Medical Records or Health Information, or “VA Form 10-5345,” is a document that allows the collection of treatment documents for physicians or health care providers once their active service is completed, if they have already been treated somewhere in a veteran facility. To report privacy incidents, email the Privacy Office at [email protected] or call 415-750-2135. To report data security incidents, email the VA Information Security Office at the [email protected] address. More information can be found on the radiation safety committee website (only accessible behind the VA firewall) or by email [email protected].

ORD Covid-19 SharePoint Website (accessible only after the VA firewall) 38 U.S.C. Section 7332 makes all records going to contain the identity, diagnosis, prediction or treatment of patients or subjects for substance abuse, alcoholism or alcohol abuse, human immunodeficiency virus infection (HIV/AIDS), or Sickle Cell Anemia strictly confidential. This status applies to information, whether it is recorded in a document or in a minutes. Download the HIPAA form in iRIS in other study documents – don`t download them in the Consent section. If you have any questions, contact the data protection officer going to the [email protected] address. You must obtain permission from the VA Assistant ACOS for the search in order to restart in-person search visits at SFVA. For more information, please contact Dr. Jennifer Mitchell ([email protected]). Notification of Privacy and Information Security Incidents The following language regarding the treatment and compensation of research-related injuries must be included verbatim in authorization forms goes for more than minimal risk studies: If you wish to inform non-ELIGIBLE patients by publishing/distributing recruitment materials on the premises of a facility goes, no authorization is required. Contact the VA (email protected) clinical research office to discuss how to allow the use of non-VA study notices. Fill out the Study Information section (page 1) of this form and download it in the Other Study Documents section of your iRIS repository for all the first contributions and changes that SFVA adds as a website.

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