Children's Hospital Colorado

Decedent Research Certification Request

This form is for investigators who need access to Children's Hospital Colorado's Medical Records, Databases or Tissue Banks for collecting protected health information (PHI) from individuals who are deceased for the purpose of research.

You must submit this form to Children's Colorado's Research Institute for approval according to the Health Insurance Portability and Accountability Act of 1996.

Note: Fields marked with * are required.

Is this research funded? *
Is a contract in place (or are negotiations in progress) for this project? *
Agreement type
Source of data *
Which PHI elements do you plan to collect from the EMR?

The investigator makes the following certifications:
1. The research is being conducted per CHCO policy.
2. PHI being sought will be used solely for research on deceased individuals.
3. Individuals involved in this research are deceased (the RCO retains the right to request death certificates or other similar documentation for each individual); and
4. PHI being sought is necessary for the research.

By submitting this form, the investigator certifies that the above stipulations are correct in accordance with the Health Information Portability and Accountability Act of 1996. The Investigator also understands that any misrepresentation of the above information can result in civil and/or criminal penalties