Retrospective Chart Review
Informed Consent Waiver Request
Project Title:
Principal Investigator Name:
Department:
Contact Email / Phone:
1. Description of Research
Briefly describe the purpose and design of the retrospective chart review, including the data to be collected:
2. Justification for Waiver of Informed Consent
Explain how the study poses minimal risk to subjects:
Explain why the waiver will not adversely affect the rights and welfare of the subjects:
Explain why the research could not practicably be carried out without the waiver:
3. Data Confidentiality
Describe how subject confidentiality will be maintained (e.g., storage, coding, access):
4. Identifiers
List any direct identifiers to be collected/used (if any):
5. Data Access & Use
Who will have access to the data? State their roles:
Principal Investigator Signature:
Date: