Study Information

Study Title
Principal Investigator
Study ID/Protocol Number
Date of Checklist Completion
Completed by

Identifiers to Remove or Modify

Identifier	Removed/Modified?	Notes
Patient Names
Geographic Information (addresses, cities, postal codes)
Dates (birth, admission, discharge, death, etc.)
Contact Information (phone, email)
Medical Record/Account Numbers
Device Identifiers/Serial Numbers
Personal Identifiers (SSN, National ID, etc.)
Photographs/Images
Other Unique Identifiers