Patient Interview Transcript De-Identification Form
Reviewer Name
Date
Transcript Information
Transcript ID / Reference
Patient ID / Initials
De-Identified Fields Checked
Name(s)
Date of birth / Age
Address
Phone number
Email
Medical record / Patient number
Health plan number
Other direct identifiers
Other fields (specify)
Notes / Details of De-Identification
Specify methods used and any issues identified during de-identification:
Final Review
Reviewer Confirmation / Comments