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{\fbimajor\f31544\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fbimajor\f31545\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbimajor\f31546\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
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{\flominor\f31552\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flominor\f31553\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flominor\f31554\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\flominor\f31555\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flominor\f31556\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fdbminor\f31558\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
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{\fdbminor\f31563\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbminor\f31564\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fdbminor\f31565\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\fdbminor\f31566\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhiminor\f31568\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}{\fhiminor\f31569\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}
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{\fbiminor\f31578\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fbiminor\f31579\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fbiminor\f31581\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\fbiminor\f31582\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbiminor\f31583\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fbiminor\f31584\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\fbiminor\f31585\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbiminor\f31586\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}}{\colortbl;\red0\green0\blue0;\red0\green0\blue255;\red0\green255\blue255;\red0\green255\blue0;
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\ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \ai\af0\afs16 \ltrch\fcs0 \cs19\i\fs16\insrsid9311558\charrsid3556764 dbase.}{\rtlch\fcs1 \ai\af0\afs16 \ltrch\fcs0 \cs19\i\fs16\insrsid3556764\charrsid3556764 application, }
{\rtlch\fcs1 \ai\af0\afs16 \ltrch\fcs0 \cs19\i\fs16\insrsid10632485 revised, 11}{\rtlch\fcs1 \ai\af0\afs16 \ltrch\fcs0 \cs19\i\fs16\insrsid9311558\charrsid3556764 /2}{\rtlch\fcs1 \ai\af0\afs16 \ltrch\fcs0 \cs19\i\fs16\insrsid10632485 010}{\rtlch\fcs1 
\ai\af0\afs16 \ltrch\fcs0 \cs19\i\fs16\insrsid13204485\charrsid3556764  }{\rtlch\fcs1 \ai\af0 \ltrch\fcs0 \i\insrsid5142868\charrsid3556764 
\par }\pard\plain \ltrpar\s17\ql \li0\ri0\widctlpar\tqc\tx4320\tqr\tx8640\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid5142868 
\par }}{\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang {\pntxta )}}
{\*\pnseclvl5\pndec\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8
\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\pard\plain \ltrpar\s1\ql \li-86\ri0\sb240\sa60\sl-180\slmult0
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\ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid11686927 {\shp{\*\shpinst\shpleft-99\shptop251\shpright1281\shpbottom1586\shpfhdr0\shpbxcolumn\shpbxignore\shpbypara\shpbyignore\shpwr4\shpwrk0\shpfblwtxt1\shpz0\shplid1026
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\scaps\insrsid10959553\charrsid12017392  Registration Form}{\rtlch\fcs1 \af1 \ltrch\fcs0 \scaps\insrsid5515541\charrsid12017392 
\par }\pard\plain \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid10959553 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \ab\ai\af0\afs22 
\ltrch\fcs0 \b\i\fs22\ul\insrsid10959553\charrsid10959553 Note: }{\rtlch\fcs1 \ai\af0\afs22 \ltrch\fcs0 \i\fs22\insrsid10959553\charrsid10959553  This form applies to databases that are developed and/or used exclusively for
\par }{\rtlch\fcs1 \ai\af0\afs22 \ltrch\fcs0 \i\fs22\insrsid10959553 research}{\rtlch\fcs1 \ai\af0\afs22 \ltrch\fcs0 \i\fs22\insrsid10959553\charrsid10959553  or recruitment purposes and not for patient care.
\par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12017392 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12017392 
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \fs20\insrsid12017392\charrsid15100138 IRB }{\rtlch\fcs1 \af0 \ltrch\fcs0 \fs20\insrsid5142868\charrsid15100138 Project Title:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \fs20\insrsid10959553\charrsid15100138  }{\rtlch\fcs1 \ab\af0 
\ltrch\fcs0 \b\fs20\insrsid10959553\charrsid15100138  }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid10959553\charrsid15100138  FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid10959553\charrsid15100138 
{\*\datafield 000000001400000005546578743700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text7}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\lang1024\langfe1024\noproof\insrsid10959553\charrsid15100138 \u8194
\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \fs20\insrsid5142868\charrsid15100138 \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\fs20\insrsid12017392\charrsid15100138 \tab \tab \tab \tab \tab 
\par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12077944 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid13649207\charrsid15100138 
\par }\pard \ltrpar\qj \fi720\li5760\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin5760\itap0\pararsid12017392 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid12017392\charrsid15100138 Registration: Type}{\rtlch\fcs1 \ai\af0\afs20 
\ltrch\fcs0 \i\fs20\ul\insrsid12017392\charrsid15100138  (check one)
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid12017392\charrsid15100138  FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid12017392\charrsid15100138 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af0\afs22 \ltrch\fcs0 \fs20\insrsid12017392\charrsid15100138 \tab Initial database registration
\par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12017392 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid12017392\charrsid15100138 Principal Investigator: }{\field\fldedit{\*\fldinst {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid12017392\charrsid15100138  FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid12017392\charrsid15100138 {\*\datafield 000000001400000005546578743800000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text8}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\lang1024\langfe1024\noproof\insrsid12017392\charrsid15100138 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid12017392\charrsid15100138          \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid15100138 \tab }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid12017392\charrsid15100138  FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid12017392\charrsid15100138 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af0\afs22 \ltrch\fcs0 \fs20\insrsid12017392\charrsid15100138 \tab Database information update
\par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid5142868 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid268697\charrsid15100138 
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid13649207\charrsid15100138 
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid9780757\charrsid15100138 
\par }\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid268697 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid9780757\charrsid15100138 1.\tab 
Database name: For registration purposes, please name the database.  }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid9780757\charrsid15100138  FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs20\ul\insrsid9780757\charrsid15100138 {\*\datafield 000000001400000005546578743700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text7}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs20\ul\lang1024\langfe1024\noproof\insrsid9780757\charrsid15100138 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs20\ul\insrsid9780757\charrsid15100138 
\par 
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid9780757\charrsid15100138 2.\tab Database custodian:  For registration purposes, please designate a custodian who will be accountable for research uses of the database.  
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid13649207\charrsid15100138 \tab Name:  }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid13649207\charrsid15100138  FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs20\ul\insrsid13649207\charrsid15100138 {\*\datafield 000000001400000005546578743700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text7}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs20\ul\lang1024\langfe1024\noproof\insrsid13649207\charrsid15100138 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs20\insrsid13649207\charrsid15100138 
\par \tab Email:  }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid13649207\charrsid15100138  FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid13649207\charrsid15100138 {\*\datafield 
000000001400000005546578743700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text7}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\lang1024\langfe1024\noproof\insrsid13649207\charrsid15100138 \u8194\'20\u8194\'20
\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid13649207\charrsid15100138 
\par \tab Phone Number: }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid13649207\charrsid15100138  FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid13649207\charrsid15100138 {\*\datafield 
000000001400000005546578743700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text7}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\lang1024\langfe1024\noproof\insrsid13649207\charrsid15100138 \u8194\'20\u8194\'20
\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid13649207\charrsid15100138 
\par 
\par }\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid15149580 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid9780757\charrsid15100138 3}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs20\insrsid268697\charrsid15100138 .\tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid9780757\charrsid15100138 Is t}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid268697\charrsid15100138 his database being used to establish the
 manipulation and storage of data/specimens for the purposes of research}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid5515541\charrsid15100138 ?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid268697\charrsid15100138  }{\rtlch\fcs1 \af0\afs22 
\ltrch\fcs0 \fs20\insrsid15100138 
\par \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid268697\charrsid15100138  FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid268697\charrsid15100138 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af0\afs22 \ltrch\fcs0 \fs20\insrsid268697\charrsid15100138    YES}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid15100138          }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid268697\charrsid15100138 
 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid268697\charrsid15100138 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid268697\charrsid15100138     NO}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid15149580 
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid15100138 
\par }\pard \ltrpar\qj \li360\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid15100138 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid15100138\charrsid15100138 4.\tab Describe the type of electronic hea
lth data being stored:  }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid15100138\charrsid15100138  FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid15100138\charrsid15100138 {\*\datafield 
000000001400000005546578743700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text7}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\lang1024\langfe1024\noproof\insrsid15100138\charrsid15100138 \u8194\'20\u8194\'20
\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid15100138\charrsid15100138 
\par 
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid15100138\charrsid15100138 5.\tab Describe the physical location }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid15100138 (building/room number) }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs20\insrsid15100138\charrsid15100138 of the database:  }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid15100138\charrsid15100138  FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid15100138\charrsid15100138 
{\*\datafield 000000001400000005546578743700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text7}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\lang1024\langfe1024\noproof\insrsid15100138\charrsid15100138 \u8194
\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\ul\insrsid15100138\charrsid15100138 
\par }\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid15149580 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid15149580\charrsid15100138 
\par }\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid15100138 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs20\insrsid15100138 6}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs20\insrsid15149580\charrsid15100138 .\tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \fs20\insrsid15149580\charrsid15100138 Workstation Use - used to send, receive, store, or access electronic protected health information (\'93EPHI\'94
) shall be used in a secure and appropriate manner}{\rtlch\fcs1 \af0 \ltrch\fcs0 \fs20\insrsid15100138 .  }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\fs20\insrsid15149580\charrsid15100138 
To help ensure proper access and use of workstations, the following procedures shall be followed}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\fs20\insrsid15100138 .  Please check each box to certify compliance with applicable criteria:}{\rtlch\fcs1 \af0 \ltrch\fcs0 
\b\fs20\insrsid15149580\charrsid15149580 
\par }\pard\plain \ltrpar\s2\ql \fi-720\li1440\ri0\sb240\sa60\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin1440\itap0\pararsid10632485 \rtlch\fcs1 \ab\ai\af1\afs28\alang1025 \ltrch\fcs0 
\b\i\f1\fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid9908304  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\fs18\insrsid10632485\charrsid9908304 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\insrsid10632485 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15149580\charrsid15236784 
Each workforce member shall be provided unique usernames and password for utilizing workstations and related information systems.\~\~Passwords are confidential and shall not be disclosed to others;
\par }\pard \ltrpar\s2\ql \fi720\li0\ri0\sb240\sa60\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid15149580 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\fs18\insrsid10632485\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\b0\i0\f0\fs18\insrsid15149580\charrsid15236784 Workstations which are used to access and store EPHI shall be located in secure areas;
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15149580\charrsid15236784 
Workstation monitors shall be positioned in a manner so as to restrict viewing to authorized personnel only;
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15149580\charrsid15236784 Active workstations shall not be left unattended for prolonged periods of time.  
\par }\pard \ltrpar\s2\ql \fi-720\li1440\ri0\sb240\sa60\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin1440\itap0\pararsid10632485 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\fs18\insrsid10632485\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\b0\i0\f0\fs18\insrsid15149580\charrsid15236784 EPHI shall not be permanently stored on the local hard drive of any workstations (laptops, tablet PCs, and handheld PCs) which are not 
permanently assigned to a specific department or unit and secure. If a server is available, original EPHI will reside on the server and will be made available on workstation(s) via active directory controlled \'93network resource folders\'94
, assigned to individual users as appropriate; 
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15149580\charrsid15236784 Where appropriate, backup of workstation data, programs, and computer systems shall be perfor
med on a regular basis to protect against business interruption;
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \fs18\insrsid10632485\charrsid15236784 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15149580\charrsid15236784 At the close of business or at the end of a workforce m
ember's utilization of a workstation, the user shall close out of application sessions and be logged off the network.}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f0\fs18\insrsid15149580\charrsid15236784 
\par }\pard\plain \ltrpar\qj \li360\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid5142868 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 
\ab\af0\afs22 \ltrch\fcs0 \b\fs22\insrsid15149580 
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10959553 
\par }\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid10959553 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15100138 
\par 
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15236784 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid15236784\charrsid15236784 
\par }\pard \ltrpar\ql \fi-360\li720\ri-360\sa240\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-360\lin720\itap0\pararsid15236784 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid15236784\charrsid15236784 7.\tab Workstation Security \endash  }{
\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid15236784 t}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid15236784\charrsid15236784 o ensure that all workstations and servers are secure, the following measures shall be implemented}{\rtlch\fcs1 
\af0\afs20 \ltrch\fcs0 \fs20\insrsid15236784 .  }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\fs20\insrsid15236784 Please check each box to certify compliance with applicable criteria:}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid15236784\charrsid15236784 
\par }\pard\plain \ltrpar\s2\ql \fi720\li0\ri-360\sb240\sa60\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin-360\lin0\itap0\pararsid15236784 \rtlch\fcs1 \ab\ai\af1\afs28\alang1025 \ltrch\fcs0 
\b\i\f1\fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\fs18\insrsid15236784\charrsid15236784 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15236784\charrsid15236784 
Workstations that are used to store EPHI must be not be set-up in public or general access areas. }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15236784 
\par }\pard \ltrpar\s2\ql \fi-720\li1440\ri-360\sb240\sa60\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin-360\lin1440\itap0\pararsid15236784 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\fs18\insrsid15236784\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784 \tab }{\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 
\b0\i0\f0\fs18\insrsid15236784\charrsid15236784 A}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15236784\charrsid15236784 
ll unattended workstations must either be logged off or secured by a password if the user plans to be away from the workstation.}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15236784 
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15236784\charrsid15236784 
All workstations must either have automatic log-off or automatic lock-out capabilities, as deemed appropriate by physical location security.
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15236784\charrsid15236784 User network accounts must be temporarily disabled after five (5) invalid sign-on attempts. These dis
abled accounts must be manually reset by the system administrator.
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15236784\charrsid15236784 EPHI must
 not be stored on the local hard drive of a workstation that is not permanently assigned to a specific individual and maintained in a secure location.
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \fs18\insrsid15236784 \tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b0\i0\f0\fs18\insrsid15236784\charrsid15236784 
All users who remove workstations or media from the organization shall take reasonable precautions to physically secure the device(s) and media.
\par }\pard\plain \ltrpar\qj \fi-360\li720\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid10959553 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 
\af0\afs20 \ltrch\fcs0 \fs20\insrsid15236784\charrsid15236784 
\par }\pard \ltrpar\qj \li360\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid5142868 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15236784 \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs18 
\ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\insrsid15236784 \tab Other }{
\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\insrsid15236784\charrsid15236784 security precautions that have been implemented}{\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\insrsid15236784  - explain}{\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 
\fs18\insrsid15236784\charrsid15236784 :  }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\ul\insrsid15236784\charrsid15236784  FORMTEXT }{\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\ul\insrsid15236784\charrsid15236784 {\*\datafield 
000000001400000005546578743700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text7}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\ul\lang1024\langfe1024\noproof\insrsid15236784\charrsid15236784 \u8194\'20\u8194\'20
\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\insrsid10959553\charrsid15236784 
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15236784 
\par 
\par }\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid14708923 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid12257413\charrsid14708923 8.\tab }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\fs20\insrsid14708923\charrsid14708923 Transmission Security - Research study sites shall implement measures to protect the security of EPHI when transmitted electronically from one point to another}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\fs20\insrsid14708923  and }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid14708923\charrsid14708923 it must be protected in a manner commensurate with the associated risk of unauthorized access.}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\fs20\insrsid14708923 
\par 
\par \tab Do you plan to transmit EPHI by use of email or the Internet?  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\insrsid14708923\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 
\fs18\insrsid14708923\charrsid15236784 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\insrsid14708923   YES   }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\insrsid14708923\charrsid15236784 
 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\insrsid14708923\charrsid15236784 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\insrsid14708923   NO  }{\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \b\fs18\insrsid14708923\charrsid14708923 If yes,}{
\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \fs18\insrsid14708923  }{\rtlch\fcs1 \af0\afs18 \ltrch\fcs0 \b\fs18\insrsid14708923\charrsid14708923 p}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\fs20\insrsid14708923 
lease check each box to certify compliance with applicable criteria:}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid14708923\charrsid14708923 
\par }\pard\plain \ltrpar\s2\ql \fi720\li0\ri0\sb240\sa60\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid14708923 \rtlch\fcs1 \ab\ai\af1\afs28\alang1025 \ltrch\fcs0 
\b\i\f1\fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid14708923\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\fs18\insrsid14708923\charrsid15236784 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid14708923 \tab }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b0\i0\f0\fs20\insrsid14708923\charrsid14708923 
EPHI must not be transmitted over the Internet without the use of an approved encryption tool.}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b0\i0\f0\fs20\insrsid14708923 
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid14708923\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid14708923\charrsid15236784 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \fs18\insrsid14708923 \tab }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b0\i0\f0\fs20\insrsid14708923\charrsid14708923 Only the minimum required amount of EPHI should be transmitted electronically.}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\b0\i0\f0\fs20\insrsid14708923 
\par }\pard \ltrpar\s2\ql \fi-720\li1440\ri0\sb240\sa60\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin1440\itap0\pararsid14708923 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\fs18\insrsid14708923\charrsid15236784  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid14708923\charrsid15236784 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\insrsid14708923 \tab }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\b0\i0\f0\fs20\insrsid14708923\charrsid14708923 E-mail containing EPHI should only be sent via USA Groupwise (128-bit encryption) when no other method is appropriate. }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b0\i0\f0\fs20\insrsid14708923 
\par }\pard\plain \ltrpar\qj \li360\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid5142868 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 
\af0\afs22 \ltrch\fcs0 \fs22\insrsid12257413 
\par }\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid8930156 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid14708923 9}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\fs20\insrsid10959553\charrsid15236784 .\tab }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\cf1\insrsid10959553\charrsid15236784 Specify how long the database will exist and how remaining data will af
terwards be destroyed.  If the database will be maintained indefinitely or until the data are exhausted, then include a statement to that effect}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\cf1\insrsid8930156 : }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\fs20\cf1\insrsid10959553\charrsid15236784 \tab }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\ul\insrsid10959553\charrsid15236784  FORMTEXT }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\ul\insrsid10959553\charrsid15236784 
{\*\datafield 000000001400000005546578743700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text7}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\ul\lang1024\langfe1024\noproof\insrsid10959553\charrsid15236784 \u8194
\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\ul\insrsid10959553 
\par }\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid10959553 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\cf1\insrsid10959553 
\par }\pard \ltrpar\ql \fi-360\li720\ri0\widctlpar\wrapdefault\faauto\rin0\lin720\itap0\pararsid9908304 {\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0 \fs20\insrsid1401190 10.\tab Contingency Plan -   }{\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0 
\b\fs20\insrsid1401190\charrsid1401190  }{\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304 See Attachment A.  }{\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304 This form needs to be completed and included with the submission of 
 the Research Registration Database form.  }{\rtlch\fcs1 \af38\afs16 \ltrch\fcs0 \f38\fs16\insrsid9908304 
\par }\pard \ltrpar\qj \li360\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid1401190 {\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0 \b\fs20\insrsid1401190\charrsid1401190 
\par }\pard \ltrpar\qj \li360\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid5142868 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid14708923 1}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid1401190 1}{
\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid268697\charrsid8930156 .\tab }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9780757\charrsid8930156 Is i}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid268697\charrsid8930156 t practicable to obtain }{
\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid10959553\charrsid8930156 subject\rquote s privacy}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid268697\charrsid8930156  authorization to add their data/specimens to the research database}{\rtlch\fcs1 
\af0\afs20 \ltrch\fcs0 \fs20\insrsid9780757\charrsid8930156 ?}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid268697\charrsid8930156   
\par }\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid268697 {\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0 \b\fs20\insrsid268697\charrsid8930156 \tab }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid268697\charrsid8930156  FORMCHECKBOX }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid268697\charrsid8930156 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid268697\charrsid8930156 
   YES\tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid268697\charrsid8930156  FORMCHECKBOX }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid268697\charrsid8930156 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af0\afs20 \ltrch\fcs0 \fs20\insrsid268697\charrsid8930156     NO
\par }\pard \ltrpar\qj \li360\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid5142868 {\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0 \b\fs20\insrsid10365663 
\par }\pard \ltrpar\ql \fi-360\li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid10959553 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid15236784\charrsid8930156 1}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\fs20\insrsid1401190 2}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304 .}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid10959553\charrsid8930156 \tab Please choose one of the following:
\par }\pard \ltrpar\ql \fi-720\li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid10959553 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid10959553\charrsid8930156 
\par }\pard \ltrpar\ql \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid10959553 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\cf1\insrsid10959553\charrsid8930156  FORMCHECKBOX }{
\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\cf1\insrsid10959553\charrsid8930156 {\*\datafield 650000001400000008436865636b31333300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check133}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\cf1\insrsid10959553\charrsid8930156   I}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid10959553\charrsid8930156 
t is practicable to obtain subject\rquote s permission to add data/specimens to the research database.  I will use the USA approved HIPAA subject authorization template form to seek subject\rquote s permission}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\fs20\insrsid15147367\charrsid8930156 .}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid10959553\charrsid8930156 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\cf1\insrsid10959553\charrsid8930156 
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\cf1\insrsid10959553\charrsid8930156  FORMCHECKBOX }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\cf1\insrsid10959553\charrsid8930156 {\*\datafield 
650000001400000008436865636b31333300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check133}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af0\afs20 \ltrch\fcs0 \fs20\insrsid10959553\charrsid8930156   It is }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\ul\insrsid10959553\charrsid8930156 not}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid10959553\charrsid8930156  practicable to obtain subject
\rquote s permission.  I will not add data/specimens to the database unless I have a}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid14708923 n}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid10959553\charrsid8930156 
 IRB approved waiver of subject authorization to add data to the IRB approved research database.
\par }\pard \ltrpar\qj \li360\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid5142868 {\rtlch\fcs1 \ai\af0\afs22 \ltrch\fcs0 \i\fs22\insrsid14708923 
\par }{\rtlch\fcs1 \ai\af0\afs22 \ltrch\fcs0 \i\fs22\insrsid1401190 
\par 
\par 
\par 
\par 
\par 
\par }{\rtlch\fcs1 \ai\af0\afs20 \ltrch\fcs0 \b\i\fs20\insrsid9908304 
\par 
\par }{\rtlch\fcs1 \ai\af0\afs20 \ltrch\fcs0 \b\i\fs20\insrsid10959553\charrsid14708923 Investigator\rquote s Assurance:}{\rtlch\fcs1 \ai\af0\afs20 \ltrch\fcs0 \i\fs20\insrsid10959553\charrsid14708923   }{\rtlch\fcs1 \ai\af0\afs20 \ltrch\fcs0 
\i\fs20\insrsid15084682\charrsid14708923 My research team and I will comply with the use and disclosure restrictions described above}{\rtlch\fcs1 \ai\af0\afs20 \ltrch\fcs0 \i\fs20\insrsid9908304  and }{\rtlch\fcs1 \ai\af0\afs20 \ltrch\fcs0 
\i\fs20\insrsid9908304\charrsid9908304 completion of a}{\rtlch\fcs1 \af38\afs16 \ltrch\fcs0 \i\f38\fs16\insrsid9908304\charrsid9908304  risk assessment on a}{\rtlch\fcs1 \af38\afs16 \ltrch\fcs0 \i\f38\fs16\insrsid9908304 n}{\rtlch\fcs1 \af38\afs16 
\ltrch\fcs0 \i\f38\fs16\insrsid9908304\charrsid9908304  annual basis.}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \i\fs22\insrsid9189636\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9189636 
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\ul\insrsid15084682 \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\ul\insrsid9189636 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15084682 \tab \tab }{\rtlch\fcs1 \af0\afs22 
\ltrch\fcs0 \fs22\ul\insrsid15084682 \tab \tab \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15084682 
\par Signature for database registration\tab \tab \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9189636 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15084682 Date
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10959553 
\par 
\par }\pard \ltrpar\ql \li360\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid10959553 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \scaps\fs28\ulth\insrsid10959553\charrsid14708923 \tab \tab \tab \tab \tab \tab \tab \tab \tab 
\tab \tab \tab \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \scaps\fs28\insrsid10959553\charrsid14708923 
\par }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\scaps\fs28\insrsid10959553\charrsid14708923 IRB Office Use Only:
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \scaps\fs28\insrsid10959553\charrsid14708923 
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10959553\charrsid14708923  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10959553\charrsid14708923 {\*\datafield 650000001400000006436865636b3100000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10959553\charrsid14708923   Approved
\tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10959553\charrsid14708923  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10959553\charrsid14708923 {\*\datafield 650000001400000006436865636b3100000000000000000000000000
}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10959553\charrsid14708923 
  Approved Pending }{\rtlch\fcs1 \ai\af0 \ltrch\fcs0 \i\insrsid10959553\charrsid14708923 (see comments)}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10959553\charrsid14708923 \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid10959553\charrsid14708923  FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10959553\charrsid14708923 {\*\datafield 650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10959553\charrsid14708923   Not Approved
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \ul\insrsid14708923\charrsid14708923 
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \ul\insrsid10959553\charrsid14708923 Comments:  
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10959553\charrsid14708923 \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \ul\insrsid10959553\charrsid14708923 \tab \tab \tab }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10959553\charrsid14708923 

\par Reviewer\rquote s signature\tab \tab \tab \tab \tab Date
\par }{\rtlch\fcs1 \ai\af0 \ltrch\fcs0 \i\insrsid10959553\charrsid14708923 
\par }\pard \ltrpar\qc \li360\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid10959553 {\rtlch\fcs1 \ai\af0 \ltrch\fcs0 \i\insrsid10959553\charrsid14708923 
\par }\pard \ltrpar\qj \li360\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid5142868 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10959553 
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9908304 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par }\pard\plain \ltrpar\s31\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid9908304 \rtlch\fcs1 \ab\af0\afs24\alang1025 \ltrch\fcs0 \b\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid9908304 ATTACHMENT A
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9908304\charrsid9908304 TEMPLATE \endash  }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9908304 C}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9908304\charrsid9908304 ONTINGENCY PLAN
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid9908304 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid9908304\charrsid9908304 
\par 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Date:}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304  
\par 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Name of person completing form:}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304  }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\fs20\ul\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Research Database Name:}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304  
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\ul\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Software (Name and version):}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304  
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 
\par Location of the system:}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304  
\par 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Does the system contain sensitive or critical data?}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304   }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\b\fs20\insrsid9908304\charrsid9908304  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid8930156  FORMCHECKBOX }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid8930156 {\*\datafield 
650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 
\af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid8930156  }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304   }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Yes   }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 
\af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid8930156  FORMCHECKBOX }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid8930156 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304    }{\rtlch\fcs1 
\af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 No
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Purpose of the system:  
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Number of Users:}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304  
\par 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Are the backups stored off-station?  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid8930156  FORMCHECKBOX }{\rtlch\fcs1 
\af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid8930156 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304   }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Yes    }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid8930156  FORMCHECKBOX }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid8930156 {\*\datafield 650000001400000007436865636b393000000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check90}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3627497\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304    }{\rtlch\fcs1 
\af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 No  }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\ul\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 If electronic (Tapes, Disks, CDs, etc.) backups are NOT stored off station, are hard copies or other storage media kept to recover information? Explain: }{\rtlch\fcs1 \af0\afs20 
\ltrch\fcs0 \b\fs20\insrsid9908304  }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\ul\insrsid9908304 \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 
\af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Are there manual or electronic procedures for the \'93continuation of business\'94, if the main system goes down?  Yes   No
\par 
\par Procedures for \'93continuation of business\'94:
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304  
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\ul\insrsid9908304\charrsid9908304 In the event of catastro
phic events that cause major destruction to the facility or assets or events that interrupt operations but do not cause major destruction, procedures below will be followed.
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \i\fs16\insrsid9908304\charrsid9908304 Some causes include:
\par }\pard \ltrpar\ql \li360\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid9908304 {\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \i\fs16\insrsid9908304\charrsid9908304 Fire, flood, earthquake, or other natural disaster
\par }\pard \ltrpar\ql \fi360\li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid9908304 {\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \i\fs16\insrsid9908304\charrsid9908304 Power failures and fluctuations
\par Interference from outside electrical sources
\par Interruptions in gas, water, and other utilities
\par Mechanical failures
\par Sabotage
\par Communication failures
\par Accidental file over-write or deletion
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid9908304 {\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \i\fs16\insrsid9908304\charrsid9908304 
\par Some effects/ consequences include:
\par }\pard \ltrpar\ql \li360\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid9908304 {\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \i\fs16\insrsid9908304\charrsid9908304 Loss of vital records and data}{\rtlch\fcs1 \af0\afs16 
\ltrch\fcs0 \fs16\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \i\fs16\insrsid9908304\charrsid9908304 Loss of communication systems}{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \i\fs16\insrsid9908304\charrsid9908304 Possible failure of computer security programs}{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \i\fs16\insrsid9908304\charrsid9908304 Inability to use critical programs}{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid9908304\charrsid9908304 
\par }\pard \ltrpar\ql \fi360\li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid9908304 {\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \i\fs16\insrsid9908304\charrsid9908304 
Extended periods of operating at less than normal efficiency}{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid9908304\charrsid9908304 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid9908304 {\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 
\par }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 Procedures in event of failure:}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304  }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid9908304\charrsid9908304 
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 \hich\af0\dbch\af0\loch\f0 1)\tab}}\pard \ltrpar\ql \fi-360\li1440\ri0\widctlpar
\jclisttab\tx1440\wrapdefault\aspalpha\aspnum\faauto\ls8\ilvl1\adjustright\rin0\lin1440\itap0\pararsid9908304 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 The failure will be reported to the database manager
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 \hich\af0\dbch\af0\loch\f0 2)\tab}The database manager will determine the nature of the failure
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 \hich\af0\dbch\af0\loch\f0 3)\tab}Manual procedures will be instituted if necessary
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 \hich\af0\dbch\af0\loch\f0 4)\tab}The database manager will work in conjunction with in-house Information Technology staff to:
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 \hich\af0\dbch\af0\loch\f0 (a)\tab}}\pard \ltrpar\ql \fi-360\li1440\ri0\widctlpar
\jclisttab\tx1440\wrapdefault\aspalpha\aspnum\faauto\ls7\ilvl1\adjustright\rin0\lin1440\itap0\pararsid9908304 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 Determine the extent of damage to both the hardware and software
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 \hich\af0\dbch\af0\loch\f0 (b)\tab}Assist in hardware and software recovery
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 \hich\af0\dbch\af0\loch\f0 (c)\tab}Secure the backup of media from storage site
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 \hich\af0\dbch\af0\loch\f0 (d)\tab}Reinstall the backup media
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 \hich\af0\dbch\af0\loch\f0 (e)\tab}Test the system
\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 \hich\af0\dbch\af0\loch\f0 (f)\tab}Reassign passwords
\par }\pard \ltrpar\qj \li360\ri0\widctlpar\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid5142868 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid9908304\charrsid9908304 
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