0920-0891 WTCHP Youth Research Cohort HIPAA Authorization Form_10F

Form Approved
OMB No. 0920-0891
Exp. Date XX/XX/20XX

WORLD TRADE CENTER HEALTH PROGRAM
HIPAA Authorization for Youth Research Cohort
The U.S. Department of Health and Human Services (HHS), Centers for Disease Control and Prevention
(CDC), National Institute for Occupational Safety and Health (NIOSH), World Trade Center (WTC) Health
Program may collect or maintain protected health information regarding members of the WTC Health Program
and/or participants in Program-related research.
With this authorization, I hereby give permission to HHS/CDC/NIOSH/WTC Health Program to disclose the
protected health information outlined below to researchers as described below for the purposes further
described.
Name of Individual to Whom this Authorization Pertains:
_________________________________________________________________________________
(NAME OF INDIVIDUAL)

_________________________________________________________________________________
(DATE OF BIRTH OF INDIVIDUAL)

To Whom Disclosure of Protected Health Information is Authorized:
The disclosure of personal health information will be made to approved applicants following competitive award
of public health research. The award follows evaluation for scientific and technical merit through the
CDC/NIOSH peer review system. Applicants seeking personal health information for awarded research are
responsible for ensuring that the Project/Performance Site operates under appropriate Federal Wide
Assurance for the protection of applicable research privacy and human subjects protections described in Part II
of the SF 424 (R&R) Application Guide and in the HHS Grants Policy Statement.
Purpose of Disclosure of Protected Health Information:
The protected health information (PHI) will be disclosed for purposes of future youth cohort research studies.
Your PHI maintained in the registry will be disclosed to researchers upon their request for the recruitment of
participants in awarded research conducted under an Internal Review Board (IRB)-reviewed research protocol.
Information disclosed will be the minimum necessary for the WTC Health Program to carry out its purpose, and
may include (please check all that apply and describe any exclusions within each checked category):
☐Name
☐Sex
☐Race and Ethnicity
☐Date of birth
☐Mailing address
☐Phone number
☐Email address
☐Self-reported characteristics of exposure (i.e., location, duration, and whether the exposure occurred
prenatally or postnatally)
Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer;
1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-0891).

☐Other: _________________________________________________________________________________
Exclusions:
_________________________________________________________________________________
_________________________________________________________________________________

This authorization expires when I choose to exercise my right to revoke this authorization. I understand that I
may revoke this authorization in writing at any time by sending written notification to the WTC Health Program:
ATTN: WTC Health Program Privacy Officer
400 7th Street SW, Suite 5W
Washington D.C. 20024
or by email: wtchpprivacy@cdc.gov
Use or disclosure of my protected health information by the WTC Health Program made prior to the WTC
Health Program’s receipt of my written request to revoke this authorization will be governed by this
authorization to the extent that the WTC Health Program has taken any action in reliance on this authorization
already.
Signing this authorization is voluntary. The WTC Health Program may not condition treatment, payment,
enrollment, or eligibility for benefits on the signing of this authorization. The information disclosed under this
authorization may be subject to further disclosure by the authorized recipient(s); such additional disclosures by
third parties are not subject to, nor protected by, this authorization. The WTC Health Program will give me a
copy of this signed authorization, upon request. Requests may be made in writing to the above address.
_________________________________

_________________________________

Printed Name of Individual

Date of Birth

_________________________________

_________________________________

Address

WTC Health Program 911#, if applicable

_________________________________

_________________________________

Address Line 2

Phone

_________________________________

_________________________________

Signature

Date