Hipaa De-Id Certification Form Page 2

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Principal Investigator’s Certification
I certify that the Protected Health Information (PHI) that will be received or reviewed by research
personnel for the research project referenced above will not include any of the 18 identifiers
listed above. I also certify that I do not have knowledge that any of the remaining information
could be used, alone or in combination with other information, to identify an individual who is the
subject of the information.
_____________________________________
____________
Principal Investigator
Date
Approved by: IRB
Name:
Date:
Signature:____________________
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