The Human Subjects Office in collaboration with Information Technology Services has developed a web-based IRB application and review system, called HawkIRB. • I know that the information in this form includes the known effects and risks. var bugzillaReferrer = window.location.href; Department of Radiology I have seen and read the material to be published. The HawkIRB system includes: Consent forms, scripts, advertisements and other materials can be uploaded to HawkIRB during your application. 1,063 Templates. DOT Medical Examination Report Form. A summary of the HawkIRB Development and Implementation Process was presented to the Associate Deans for Research on 1/28/04. Consent Form for Publication in a PLOS Journal I, the undersigned, give my consent for my or my minor child’s (insert name below, where indicated) photograph, other image or likeness, case history or family history to be published in a Public Library of Science (PLOS) Journal. Any claim (hospital, operating physician, anesthesiologist, clinic, etc) involved in a sterilization procedure must have a properly completed Consent Form attached when it is submitted for payment. 2. UnitedHealthcare Clinical Services and Therapy Request Form . UIHC patients only CONSENT TO RELEASE OF INFORMATION Hosp. • All of my questions have been answered to my satisfaction. This site is designed to be a central repository for electronic forms used by students, faculty, and staff members at the U of I. Use our HIPAA-compliant form to authorize the release of medical information - Consent to Release of Information. The school’s ability to discipline your child under the school’s disciplinary code and procedures. 200 Hawkins Drive Iowa City, IA 52242-1089, Copyright © 2021 The University of Iowa. If you would like to submit a question for consideration as an addition to the FAQ, please send an e-mail to hawkirb@uiowa.edu. HIM and the Quality Improvement Program have developed a new Consent for Refusal of Blood Products form and document type ‘Consent for Refusal of Blood Products.’ This is a multi-phase project. Referral to Hawkeye Oral Surgery 6. Broker Authorization: The undersigned hereby requests Oxford Health Plans to accept the Broker or General Agent named below as an authorized Benefits Administrator for purposes of processing any enrollment transactions for my company’s Oxford Health Plan policy (including, but not limited to, Member … UHC – MEDICATION SOURCING EXPANSION PRESCRIBER ORDER FORM: Submit completed form and clinical documentation. Student Involvement Immunization Form. Hepatitis B. Roy Carver College of Medicine consent templates (standard informed consent, VAMC informed consent, UIHC Record of Informed Consent, Assent, Spanish “short form” consent, consent as a letter) project closure form; Consent forms, scripts, advertisements, and other materials can be uploaded to HawkIRB during your application. Fax: 319-335-7310irb@uiowa.edu, HawkIRB Development and Implementation Process, forms and/or instructions that are not available on the HawkIRB, UI Investigator's Guide\IRB Standard Operating Procedures, Central & External IRBs (Single IRB of Record), on-line submission of application forms and Consent Documents, an electronic workflow process through which you will communicate with the IRB regarding review and approval of your applications, a "My Projects" home page through which you will be able to view detailed IRB workflow information about all of your projects, IRB approval memos and stamped Consent Documents returned to you electronically -- no more waiting for campus mail, reminder notices for continuing review sent by e-mail to PIs and contact persons, applications for new projects, modifications, and continuing reviews, forms for reporting unanticipated problems and adverse events (REFs), consent templates (standard informed consent, VAMC informed consent, UIHC Record of Consent, Assent, Spanish "short form" consent, consent as a letter). #_____ University of Iowa Hospitals and Clinics (UIHC) Health Information Management Department; Release of Information Office 200 Hawkins Dr., Iowa City, IA 52242 (Telephone 319-356-1719; FAX 319-356-3079) Please use blue or black ink, neatly PRINT (except signature) and provide complete information in each section. Iowa KidSight is a joint project of the Lions Clubs of Iowa and the Department of Ophthalmology & Visual Sciences at the University of Iowa Stead Family Children’s Hospital, dedicated to enhancing the early detection and treatment of vision impairments in young children (target population 6 months of age through kindergarten) in Iowa communities through screening and public education. Additionally, I agree that this Consent Form does not authorize anyone to receive individually identifiable health information about any Oxford member. Allow the child to access the school’s internet network. Referral to Operative Dentistry - Electronic or Printable 4. Sterilization Consent Form (English) Sterilization Consent Form (Español) Sterilization Consent Form FAQ; Stay Informed. Hosp. • I have had enough opportunity to discuss treatment options with my health care provider. Other procedure-specific consent forms … The forms are organized alphabetically by department with instructions for their use just a mouse click away. Patient consent forms: Panel tests: Patient informed consent Panel tests (Spanish): Patient informed consent Exome tests: Patient informed consent Authorization to use and disclose health information Please note that there is no paper requisition form for exome testing. Referral to Oral Pathology, Radiology & Medicine 7. (Non-patient forms are retained by the department acquiring consent). All applications for UI IRB review must be submitted through HawkIRB. Release of Information Office (Telephone 319-356-1719; FAX 319-356-3079) Please neatly PRINT (except signature) and provide complete information in each section. UHC Psychological Testing Consent Form. Member Consent for Referring Out -of-Network Form UnitedHealthcare maintains a nationwide network of care providers. Tdap Vaccine Information & Waiver. #_____ UI Sports Medicine and University of Iowa Hospitals and Clinics (UIHC) Please use blue or black ink, neatly PRINT (except signature) and provide complete information in each section. Nondiscrimination Statement, Up-to-date information regarding COVID-19 for College of Medicine students and researchers, Assigning On-Call Responsibilities for General Radiology, On-Call Policy for Interventional Radiology Nursing Staff, Administration of Contrast via Indwelling CVC in the Adult or Pediatric Patient, Administration of Enteric and IV Contrast on Inpatient Unit, Adult Contrast Reaction Management in SFCH LL2, Contrast Policy for Adult Patients Receiving CT Abdomen/Pelvis: Bladder Cancer, Contrast Protocol for CTA Brain and Cerebral Perfusion and CT Brain, CTA Brain and Cerebral Perfusion, Education Sheet for Patients Receiving IV Contrast, Intraosseous Iodinated Contrast Injection Guidelines, IV Contrast Administration for Patients with Limited English Proficiency, Policy on Education for Patients Receiving IV Contrast, Protocol for Adult CT Abdomen/Pelvis Trauma with Delays (Cysto); CT Abdomen/Pelvis Trauma w/o Delays; CT Chest, Abdomen/Pelvis with delays; all of which can be done w/wo IV Contrast, Protocol for Adult CT Chest, Abdomen/Pelvis with Contrast Media; CT Chest, Abdomen/Pelvis without Contrast Media in Patients for Follow-up Melanoma and Sarcoma, Protocol for Adult CTA of Head with Contrast Media; CTA of Neck with Contrast Media; CTA of Head and Neck with Contrast Media, Protocol for Adult Patients Receiving CT for Abdomen/Pelvis with Contrast Media or Abdomen/Pelvis without Contrast Media in Acute Abdomen and/or Pelvis, Protocol for Adult Patients Receiving CT Abdomen with Contrast Media; CT Abdomen and Pelvis with Contrast Media; CT Chest, Abdomen and Pelvis with Contrast in Patients for Biphasic Liver Exams, Protocol for Adult Patients Receiving: Right, Left and Bilateral CT Angio Lower Extremity w/wo Contrast; CT Angio Abdomen/Pelvis with Bilateral Lower Leg Runoff w/wo; CT Angio Pelvis with Single Lower Extremity Runoff w/wo, Management of Unresolved Serious Complaints in Breast Imaging, Self and Direct Referral Patients for Mammography, Body Imaging Percutaneous Procedures Anticoagulation Guidelines, CT IV Size Protocol for Pediatric Patients, CT of Patients with Implantable and External Electronic Medical Devices, Policy for Routine CT Abdomen without Contrast Media for Post Chemo Embolization, Hernia, and Follow-up Drainage Tube Placement by Interventional Radiology, Portable Head Computed Tomography (CT) without Contrast Media, Protocol for Routine CT Abdomen/Pelvis without Contrast Media for Renal Stones, Hernia, and Follow-Up Drainage Tube Placement by Interventional Radiology, Image Management After Hours Staff for Archive Corrections, Image Management Archive Corrections After Hours, Release of CD Exams to Patient and/or Another Party, ardiac Stress Testing of Adult Patients Using MR Imaging, Emergency Situations in the MR Environment, MR Imaging of Adult Patients with FDA-Approved Cardiac Implantable Electronic Devices (CIED), MR Imaging Protocol for Patients with Implanted Neurostimulators, MRI of Pediatric and Adult Congenital Heart Disease (ACHD) Patients with FDA-Approved Cardiac Implantable Electronic Devices (CIED), Procedure for Patients that are Breast Feeding After the administration of Gadolinium Intravenously, MRI Scanning of Patients with Intravascular Stents, Coils and Heart Valves, Fine Needle Spinal Procedures and Anticoagulation, Call Tree for Full Scale Hospital Disaster, Code Blue Responsibilities for Radiology Staff, Radiant Quicksheet - EPIC Downtime Process, Career Development for Imaging Technologists, Charge Technologist in the Department of Radiology, CT Weekend Option and Weekend Scheduling to Cover Vacation for Weekend Option, Diagnostic Radiology Protocol for Assuring Registration/Certification/Permit Compliance, Dress Code Policy for Clinical Staff in Diagnostic Radiology, Guidelines for Monitoring and Correcting Technical Errors, Guidelines for the Use of Personal Electronic Devices - Diagnostic Radiology, Licensure and Certification for Technologists and Sonographers, MR and CT Call Coverage During Vacancy/Illness, MRI Weekend Option and Weekend Scheduling to Cover Vacation for Weekend Option, Reclassification Application for Imaging Technologists, Reporting Concerns Regarding Clinical Quality, Protocol for Oral Diazepam and/or Lorazepam for Outpatient Adult MRI, Nuclear Medicine and Ultrasound Patients Requiring Oral Sedation, Informed Consent, Time Out and Site Marketing, Information Sheet for Undergoing an MRI During Pregnancy, Policy for Pregnant or Possibly Pregnant Patients, G-2d2 Consent Form for Imaging of the Abdomen or Pelvis in Pregnancy where the Dose is 1-5 rem, G-2d2 Consent Form for Imaging of the Abdomen or Pelvis in Pregnancy where the Dose is Greater than 50mSv (5 rem), Procedure for Imaging Patients that are Pregnant Utilizing an MRI Scanner, Film Repeat Rate by Technologist and Clinical Area, Integrity of Lead Aprons and Thyroid Shields, Integrity of Radiation Protection Equipment Form, Interoperative Shielding During Fluoroscopy Guided Exams in the Pediatric Patient, Mandatory Admission due to Postoperative Apnea Risk Following Sedation and Anesthesia for Infants, Management of Adverse Patient Events or Outcomes in the Radiology Department, Monitoring for Apnea after General Anesthesia, Deep Sedation or Spinal Anesthesia in Young Infants, OR Images for Sponge Count or Foreign Object, Radiation Protection Guide for Medical Use of Radioactive Materials & Radiation Producing Machines, Radiology Bariatric Chair Location Log Sheet, Suggested Procedure for Contacting Caregivers, Witnessing the Disposal of Controlled Substances, Critical Results Requiring Immediate Clinical Notification - Chest, Critical Results Requiring Physician Notification. 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