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Case Study Template

Case Study Template. Kerecis Aurora Awards. Download case study template and consent form Fill out consent form and obtain appropriate consents Fill in slide 2 with your name, facility, submission category Fill out slide 3 with past wound history and management details

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Case Study Template

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  1. Case Study Template Kerecis Aurora Awards Download case study template and consent form Fill out consent form and obtain appropriate consents Fill in slide 2 with your name, facility, submission category Fill out slide 3 with past wound history and management details Fill out slide 4 for current wound history and management For additional photos, copy slide 4 as many times as necessary to share wound progression When complete, submit case with consent form

  2. Case Study Template Type of wound: ex. Diabetic ulcer

  3. Past wound history and management

  4. Current wound history and management Wound picture Name of wound: i.e. DFU- Left leg Aside from picture of wound, please include pictures of Kerecis on wound, application techniques, etc

  5. THE COMMITTEE ON HUMAN RESEARCH • Please ensure all patient identifiers are removed per the HIPPA Guidelines • HIPAA-PHI: List of 18 IDENTIFIERS AND DEFINITION of PHI • List of 18 identifiers: • Names: all geographical subdivisions smaller than a state, including street address, city, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code, if according tot the current publicly available data from the Bureau of the Census: (1) The geographic unit formed by combining all of the zip codes with he same three initial digits contains more than 20,000 people; and • The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000. • All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates(including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older; • Phone numbers; • Fax numbers; • Electronic mail addresses; • Social Security numbers; • Medical record numbers; • Health plan beneficiary numbers; • Account numbers; • Certificate license numbers; • Vehicle identifiers and serial numbers, including license plate numbers; • Device identifiers and serial numbers; • Web Universal Resource Locators (URLs); • Internet Protocol (IP)address numbers; • Biometric identifiers, including finger and voice prints; • Full face photographic images and any comparable images; and • Any other unique identifying number, characteristic, or code (note this does not mean the unique code assigned by the investigator to code data)

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