The Health Insurance Portability and Accountability Act _HIPAA_ of

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					IRB Docket #: _________________

Approval Date: ________________

                              UMass Memorial Medical Center

                  Accounting of Research Disclosures: Summary Form

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires covered
entities to keep an Accounting of Disclosures when patients’ Protected Health Information
(PHI) is disclosed for research without the patient’s explicit authorization. If the number of
disclosures is greater than 200, HIPAA allows the covered entity to keep a Summary
Accounting, which must contain the information below.

UMass Medical School, the entity with responsibility for approval of human research
activities, has agreed to assist UMass Memorial in meeting these HIPAA requirements.

You have received this form because pursuant to your IRB-approved research protocol,
UMass Memorial will be disclosing a large number of records to you for research purposes.
Please fill out the information below and return this form to:

Office of Vice Provost for Research
UMass Medical School – Room S1-859
Attention: S. B. Noone, Asst Vice Provost for Clinical Research
55 Lake Avenue North
Worcester, MA 01655
Fax: 508.856.5400
Phone: 508.856.5015

If you have questions about this form, please contact Sheila B. Noone (x65015) or

     1. Name of person completing form:

     2. Name of Principal Investigator:

     3. UMMS IRB docket number:
        Expected number of records to be disclosed:
        Name of the protocol or other research activity (as noted on IRB application):

     4. A description, in plain language, of the research protocol or other research
        activity, including the purpose of the research and the criteria for selecting
        particular records:

Revised July 2011/OVPR                                                            Page 1 of 2
IRB Docket #: _________________

Approval Date: ________________

     5. A brief listing of the type of protected health information that was disclosed:

     6. The date or period of time during which such disclosures occurred, or may have

     7. Date of last such disclosure during the accounting period:

Acknowledged in OVPR:

___________________________________                Date: _________________________
Sheila B. Noone, Ph.D.
Asst Vice Provost, Clinical Research

Revised July 2011/OVPR                                                            Page 2 of 2

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