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Forms & Templates

On this page, you will find various forms that Military Health System uses to support its programs. Please scroll down the page or use the search box to find specific forms and templates.

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DHA Privacy Board Application for a Waiver of Authorization or an Altered Authorization

Form/Template
8/1/2012

Use this form if the researcher has not received documentation from an Institutional Review Board (IRB) or HIPAA Privacy Board approving a waiver or alteration of Authorizations and reasons exist that make it impractical or impossible for the researcher to obtain Authorizations from each research participant, the PI may submit an Application for a ...

Recommended Content:

Privacy Board

Request for Mitochondrial DNA Sequence Report

Form/Template
2/1/2012

Use this form to request a copy of your mitochondrial DNA type to help recover family member remains.

Recommended Content:

DNA Identification Laboratory

Armed Forces Medical Examiner System Consultation Request Form

Form/Template
1/2/2012

Medical information received is considered during the consultative process and is used to form a database for education and research in pathology.

Recommended Content:

Office of the Armed Forces Medical Examiner

Brand over Generic Prior Authorization Form

Form/Template
8/10/2011

This form should be completed and signed by the prescriber to request prior authorization to use a brand name drug instead of a generic equivalent.

Individual Investigator Agreement

Form/Template
3/29/2011

This form is a tool that can be used when a collaborating investigator is not part of an institution with a federal assurance.

Recommended Content:

Research Regulatory Oversight Office

Disposition of Organs Retained for Extended Examination

Form/Template
3/8/2011

Use this form to grant permission to the Armed Forces Medical Examiner System to retain organs for an extended examination to determine cause of death.

Recommended Content:

Office of the Armed Forces Medical Examiner

Institutional Agreement for IRB Review

Form/Template
8/30/2010

This form should be used when an institution will be engaged in human subject research and will use an Institutional Review Board (IRB) that is not organizationally or legally part of the institution.

Recommended Content:

Research Regulatory Oversight Office

Supplemental Health Care Program Worksheet

Form/Template
4/16/2010

Use this worksheet when referring a service member under the Supplemental Health Care Program.

Recommended Content:

Supplemental Health Care Program

DoD Addendum to the Department of Health and Human Services Federalwide Assurance for the Protection of Human Subjects

Form/Template
8/20/2009

This form is a tool to help Institutions with an existing FWA approved by DHHS to know about and acknowledge key DoD policies and requirements since the DHHS FWA does not identify DoD requirements.

Recommended Content:

Research Regulatory Oversight Office

Smallpox Vaccine Sick Call Medical Note

Form/Template
7/23/2009

This form is used to note clinical or follow-up care after receiving a smallpox vaccine.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events

Smallpox Vaccine Take Check Medical Note

Form/Template
7/23/2009

This form is used to note clinical or follow-up care after receiving a smallpox vaccine.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events

Researcher Responsibility Form

Form/Template
4/16/2009

The Office of the Under Secretary of Defense for Personnel and Readiness requires that all research investigators (principal investigators as well as associate investigators) engaged in research with one of its institutions explicitly acknowledge and accept responsibility for protecting the rights and welfare of human research subjects as stated therein.

Recommended Content:

Research Regulatory Oversight Office

Disposition of Remains Election Statment Initial Notification of Identified Partial Remains

Form/Template
4/1/2009

Used to record disposition of remains desired by the person authorized to direct disposition of remains (PADD).

Recommended Content:

Office of the Armed Forces Medical Examiner

TMDS DD Form 2930 (PIA)

Form/Template
11/1/2008

Privacy Impact Assessment (PIA) for the Theater Medical Data Store (TMDS).

Smallpox Vaccine Screening or Medical Note Continuation Page

Form/Template
2/7/2008

This form is used to identify additional Notes on Problems, Issues or Concerns of Patient or Provider related to Vaccine Assessment or Follow-up.

Recommended Content:

Smallpox | Smallpox Vaccine-Associated Adverse Events
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