Springfield Committee for Research Involving Human Subjects
Southern Illinois University School of Medicine Memorial Medical Center St. John’s Hospital
801 North Rutledge Street P.O. Box 19616 Springfield, Illinois 62794-9616
Telephone: (217) 545-2172 Fax: (217) 545-7873
Request for Access to PHI for Work Preparatory to Research
[Insert name of Principal Investigator (PI)] has requested permission from the Springfield
Committee for Research Involving Human Subjects (SCRIHS) to use certain patient information
to [insert description of the purposes of the PI’s use of the information].
The information to be used by the research includes:
[Provide a description of the type of patient information that the PI will be using.]
The PI represents that all the following are true and accurate:
1. Reviewing protected health information is necessary to prepare a research protocol; and
2. Information will not be removed by the PI during the review; and
3. The information is necessary for research purposes.
SCRIHS reserves the right to terminate the PI’s use of the requested information at any time if
there is reason to believe that the PI has violated any of the conditions set forth above, or has
accessed any information not described herein for any purpose not described herein.
Principal Investigator Date
This request has been reviewed and approved by the Springfield Committee for Research
Involving Human Subjects.
Chairman or Acting Chairman Date Approved
Springfield Committee for Research Involving Human Subjects
HIPAA form C