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Human Research Protection Office (HRPO)

Human Research Protection Office (HRPO)

As part of the Human Research Protection Program (HRPP) at Hennepin Healthcare, HRPO supports researchers, Institutional Review Board (IRB) members, and HRPP stakeholders to ensure appropriate protections of the rights, welfare, and wellbeing of human subjects involved in research conducted under the auspices of Hennepin Healthcare.

Hennepin Healthcare Human Research Protection Program - overview

Hennepin Healthcare compliance statement

Cayuse Human Ethics (HE) submission system

To access Cayuse Human Ethics HE: hhrin.app.cayuse.com/rs/irb

Cayuse Help Center

Visit the Cayuse Help Center for online guidance and tutorials on the Human Ethics module.

HRPO virtual office support

Have questions? HRPO staff are available from 10:30-11AM on the first & third Wednesday of every month.
Click the following link during this time for virtual office support:
https://hhrinstitute.zoom.us/j/9929368243

To request an HRPO virtual office session at another time, please contact HRPO@hhrinstitute.org

HRPO staff

 

Guidance documents

106 GUIDANCE Human research determinations (07 JAN 2025)

107 GUIDANCE Engagement determinations (2008 OHRP)

108 GUIDANCE Regulatory and external guidance references (30 APR 2026)

110 GUIDANCE Criteria for external IRB reliance (30 JAN 2026)

111 GUIDANCE Transitioning studies to 2018 Common Rule (JUN 2020)

113 GUIDANCE Notifications to HRPO for ceded studies (30 SEP 2025)

115 GUIDANCE Criteria for serving as sIRB (25 AUG 2023)

117 GUIDANCE External IRB reliance: localized language for consent forms (13 FEB 2023)

118 GUIDANCE Informed consent for investigational COVID-19 convalescent plasma - eINDs (MAR 2020)

133 GUIDANCE New information/Incident reporting (30 JAN 2026)

145 GUIDANCE IRB review of research subject to 45CFR46 (2018 Common Rule) (DEC 2020)

150 GUIDANCE Data and safety monitoring in research (25 MAR 2024)

160 GUIDANCE Criteria for exemption from IRB oversight (25 AUG 2023)

161 GUIDANCE Criteria for expedited IRB review (07 JAN 2025)

190 GUIDANCE Case reports (JAN 2021)

197 GUIDANCE Criteria for IRB approval (24 JAN 2021)

198 GUIDANCE Secondary research with de-identified data (02 FEB 2020)

199 GUIDANCE QA/QI activities (25 MAR 2024)

OHRP guidance on whether research may qualify as exempt

OHRP decision charts

FDA guidance on prompt reporting

In accordance with FDA guidance, DO NOT submit unrelated SAEs to the IRB; only report unanticipated problems that meet reporting criteria, (e.g., unexpected in nature, related to participation in the research, and resulted in new circumstances that increased the risk of harm to subjects). The Principal Investigator/study team is responsible for recording, tracking, and reporting adverse events, protocol deviations, and other unanticipated problems in accordance with sponsor and regulatory requirements, which may include information that is not reported to the IRB.

FDA guidance on research involving human specimens

Guidance on informed consent for in vitro diagnostic device studies using leftover human specimens that are not individually identifiable

21 CFR 812.3(p) (FDA Investigational device exemptions - definition of subject)

Other information

ServiceNow instructions

Research and Evaluations Data Analytics Core (REDAC)

REDCap

HHRI COI Policy

Researcher Resources

Forms

300 FORM Conflict of interest disclosure (07 JAN 2025)

306 FORM PI eligibility exception request (25 APR 2022)

315 FORM Protocol exception request (31 OCT 2022)

322 FORM Physician Chief acknowledgement (07 JAN 2025)

323 FORM Independent physician certification (25 AUG 2023)

324 FORM Community consultation and public disclosure for EFIC (MAY 2020)

330 FORM Cayuse user account request (30 JAN 2026)

332 FORM sIRB designation request (30 SEP 2025)

332-A Request for Hennepin Healthcare to serve as sIRB (25 AUG 2023)

356 FORM Closure submission for a relying site (19 MAY 2025)

373 FORM Request transfer of IRB regulatory oversight to Hennepin Healthcare IRB (07 JAN 2025)

389 FORM Information to provide HHS Privacy for a suspected breach (20 JUL 2026)

FORM A Registration for inpatient investigational drug studies (25 OCT 2022)

FORM B Registration for investigational drug not stored in pharmacy (25 OCT 2022)

Checklists

ACT CHECKLIST (ClinicalTrials.gov)

400 CHECKLIST HHS Resource Utilization Checklist (JUN 2019)

Protocol templates

620 TEMPLATE Secondary research involving data and/or specimens (30 APR 2026)

622 TEMPLATE Exempt protocol - research involving prospective data collection (30 APR 2026)

630 TEMPLATE Intervention Study (JUN 2021)

699 TEMPLATE Quality improvement project (25 AR 2024)

Informed consent templates

600 TEMPLATE Informed consent with embedded HIPAA authorization (25 MAR 2024)

601 TEMPLATE HIPAA authorization for research (13 FEB 2023)

602 TEMPLATE Informed consent for emergency use of a test article (13 FEB 2023)

604 TEMPLATE Information sheet for use of an FDA-regulated HUD (13 FEB 2023)

605 TEMPLATE Signature blocks (30 SEP 2025)

606 TEMPLATE Information sheet for EXEMPT research (13 FEB 2023)

608 TEMPLATE Consent for using body fluid/tissue samples for genetic research (11 FEB 2022)

609 TEMPLATE Letter to withdraw permission to use sample(s) for genetic research (11 FEB 2022)

661 TEMPLATE IRS reporting threshold update information sheet (30 JAN 2026)

696 TEMPLATE SMART IRB communication plan (30 JAN 2026)

699 TEMPLATE Quality improvement project (30 JAN 2026)

Information Sheet Template (to be used ONLY for prospective activities with full waiver of consent)

Informed consent FAQs

HHS.gov Informed consent FAQs

FDA – Informed Consent Guidance for IRBs, Clinical Investigators, and Sponsors (August 2023)

FDA – Use of Electronic Informed Consent - Questions and Answers Guidance for Institutional Review Boards, Investigators, and Sponsors (December 2016)

Interpreter services

Hennepin Healthcare Interpreter Services  (link requires access to InfoOnCall)

Additional information on translation and interpreter services

Using LanguageLine®

Informed consent short form

610 TEMPLATE Informed consent short form (English) (30 JAN 2026)

611 TEMPLATE Informed consent short form (Hmong) (30 JAN 2026)
- certificate of translation

612 TEMPLATE Informed consent short form (Somali) (30 JAN 2026)
- certificate of translation

613 TEMPLATE Informed consent short form (Spanish) (30 JAN 2026)
certificate of translation

614 TEMPLATE Informed consent short form (Amharic) (30 JAN 2026)
certificate of translation

615 TEMPLATE Informed consent short form (Arabic) (30 JAN 2026)
certificate of translation

616 TEMPLATE Informed consent short form (French) (30 JAN 2026)
certificate of translation

617 TEMPLATE Informed consent short form (Oromo) (30 JAN 2026)
certificate of translation

618 TEMPLATE Informed consent short form (Russian) (30 JAN 2026)
certificate of translation

619 TEMPLATE Informed consent short form (Ukrainian) (30 JAN 2026)
certificate of translation

Education & training for IRB approval

All personnel engaged in research overseen by the Hennepin Healthcare IRB must complete education/training - For specific requirements, refer to the 501 MANUAL Conducting Human Research - section 1.6 What training and education is required to conduct human research?

CITI Program:
https://www.hhrinstitute.org/citi-enrollmentaffiliation-instructions/

Hennepin Healthcare Human Subjects Protection online training for investigators conducting non-exempt research:
https://www.hhrinstitute.org/hhri-learning-center-guide/

For Office for Education & Quality in Clinical Research in-person training, contact EQ@hhrinstitute.org

HHS onboarding of medical students, residents, fellows, and shadows

Investigators wishing to engage non-employees on Hennepin Healthcare research involving human subjects must follow institutional requirements. Please contact Karin Fisher Hills: khills@hhrinstitute.org

Researchers not affiliated with Hennepin Healthcare

Do not add researchers that are external to Hennepin Healthcare to the personnel section of a Hennepin Healthcare IRB submission - human subject activities for external researchers must be approved in accordance with their own institutional requirements.

For data subject to HIPAA that is released to external researchers, a data agreement should be established (contact HHRI Grants and Contracts)

Secondary research with Epic data

For secondary research involving Epic data, researchers must provide an explanation in the IRB submission of how they will ensure that only appropriate data are accessed.

Examples of acceptable methods include:

  • Engagement with the Research & Evaluation Data Analytics Core (REDAC) to extract data for the study
    • The IRB will accept hybrid extraction, e.g., REDAC is engaged to provide required Epic data with a link to access notes data to allow researchers to extract additional data, such as information from notes
    • The IRB will accept documentation attached in the submission to confirm that REDAC has been consulted and determined that data may be extracted from Epic without REDAC involvement
  • Collaboration with an informaticist or other Epic analyst to extract data for the study
  • Explanation of expertise in data extraction within the study team – i.e., a study team member has previous experience in using Epic self-service tools (e.g., Slicer-Dicer/Workbench), including knowledge of how to apply the research restriction filter to exclude the records of patients who have opted out, as applicable

If secondary research involves ONLY de-identified data obtained via REDAC or other honest broker, the research is NOT human subject research, i.e., it is not subject to IRB oversight. For this type of secondary research, a not human research determination should be requested via Cayuse HE.

Care Everywhere

The Epic Care Everywhere user agreement states that Care Everywhere may not be used for research recruitment or to access records for research purposes. This is because Epic designed Care Everywhere to be used for treatment and care coordination purposes, and all Epic organizations that participate in Care Everywhere consent patients to its use as a patient care tool, not a research tool.  Patient Information from Care Everywhere that is already in the Hennepin Healthcare Epic system because it was previously requested for treatment or care coordination may be used for research or other lawful purpose; however, accessing Care Everywhere to retrieve/use patient information for research is not permitted.

Hennepin Healthcare Institutional Review Board

The Institutional Review Board (IRB) is charged by the federal government to protect the rights and welfare of human subjects in research.  All research involving human subjects that is conducted under the auspices of Hennepin Healthcare requires IRB approval and ongoing oversight unless determined by IRB review to be exempt.

IRB members include hospital and community representatives, scientists and non-scientists. The IRB reviews research submissions to consider the risk and benefits to subjects and to ensure that research subjects provide voluntary and informed consent.  Studies subject to IRB oversight must maintain approval throughout the conduct of the study.

IMPORTANT

You must receive written IRB approval or an exempt determination prior to initiating any study activities that involve human subjects; retrospective approval for research is unallowable.

IRB meeting schedule

Board members

Board member resources

IORG0000123
FWA00006047
IRB00000203

Study participant questions, complaints, or feedback

The Human Research Protection Program welcomes your questions, concerns, and/or feedback.

If you are a research participant and would like to discuss problems, concerns, or questions about a study, or your rights as a participant in a research study with someone other than the study Principal Investigator, please contact the Hennepin Healthcare Human Research Protection Office (HRPO).

Anyone can submit feedback, including research participants, family members, or others. To offer feedback about your experience in a research study or provide suggestions for the Human Research Protection Program, please contact us at HRPO@hhrinstitute.org,  (612) 873-6881 or complete the online Feedback Form: www.surveymonkey.com/r/ZN5JJJ2.

Other links

For drug and/or device studies, visit the links below to understand FDA requirements.

For federally funded research, the OHRP link provides information on regulatory requirements.

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