Form 10060 (04/10) 10060 (04/10) Amendment to Research/User Agreement

OMB # 1640-0012 / Expires 12/31/2013

COVER LETTER
AMENDMENT TO PRINCIPAL RESEARCHER MOA
This document is used to:
1. Extend the term of an existing Memorandum of Agreement (MOA) with a Principal Researcher
and extend access to approved Data covered under the MOA;
2. Add members to the research team under an existing MOA with a Principal Researcher so they
may have access to and use of the approved Data under the MOA; and/or
3. Delete members of the research team under an existing MOA with a Principal Researcher.
Directions:
1. Print out the Amendment.
2. Fill in appropriate information.
3. Complete the Contact Information form below with the requested information for the person who
is signing this document.
4. Sign the MOA and email it to [email protected] or fax it to the PREDICT Coordinating
Center, RTI International, Attn: Project Manager, at + 1 866 835 0255 (toll free). An executed
copy will be returned to you for your files.
Questions regarding your application may be directed to the PREDICT Coordinating Center at + 1 800
957 6422 or via email: [email protected]
Contact Information for Person Signing Document
Name
Title
Organization
Address
Address 2
City

State/Province

Country
Phone

Postal Code
Email

Alt Phone

Fax

DHS Authority to Collect This Information:  The Homeland Security Act of 2002 [Public Law 107‐296, §302(4)] authorizes the Science and Technology Directorate to conduct 
“basic and applied research, development, demonstration, testing, and evaluation activities that are relevant to any or all elements of the Department, through both intramural 
and extramural programs.” In exercising its responsibility under the Homeland Security Act, S&T is authorized to collect information, as appropriate, to support R&D related to 
improving the security of the homeland. Principal Purpose:  DHS collects name, organization and title (if any), email address, home and/or work address, and telephone 
numbers for the purpose of contacting individuals regarding the PREDICT project and/or their involvement with PREDICT. Routine Uses and Sharing:  Some of your information 
will be disclosed to PREDICT team members, such as data hosts, data providers, PREDICT contractors, the Predict Coordinating Center, the advisory board, and review board 
members to help us deliver requested PREDICT services and operate the PREDICT Web site and deliver the services you have requested. Unless you consent otherwise, this 
information will not be used for any purpose other than those stated above.  However, DHS may release this information for an individual on a case‐by‐case basis as described in 
the DHS/ALL‐002 System of Records Notice (SORN), which can be found at: www.dhs.gov/privacy. Disclosure:  Furnishing this information is entirely voluntary; however, failure 
to furnish at least the minimum information required to register (to include full name and email address,) will prevent you from obtaining authorization to access system.  

PRA Burden Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this information collection unless it displays 
a current valid OMB control number and an expiration date. The control number for this collection is 1640‐0012 and this form will expire on 12/31/2013. The estimated average 
time to complete this form is 15 minutes per respondent. If you have any comments regarding the burden estimate you can write to Department of Homeland Security, Science 
and Technology Directorate, Washington, DC 20528.  
DHS Form 10060 (4/10)  

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  Rev. 10‐7‐11 

OMB # 1640-0012 / Expires 12/31/2013

PREDICT
AMENDMENT TO PRINCIPAL RESEARCHER MOA
This document serves as an Amendment to the Memorandum of Agreement (MOA), referenced as MOA ID __________,
between __________________________ (“Principal Researcher” or “Researcher”) and Research Triangle Institute (“RTI” or
“PCC”), (individually referred to as “Party” and collectively referred to as “the Parties”), which became effective on
_______________ and signed by ______________________ as Researcher and by ________________ for RTI on
_______________, which will expire on _________________ (if MOA was previously amended, use the expiration date of
the signed Amendment). This Amendment may be used to:
A
Extend the term of the referenced MOA and extend access to approved Data covered under that MOA;
B.
Add new research team members to the referenced MOA so they may have access to and use approved Data under
the MOA; and/or
C.
Delete members of the research team under an existing MOA with a Principal Researcher.

Terms and Conditions of Amendment
1.

Indicate whether Researcher is seeking to amend the referenced MOA by placing “Yes” or “No” by the
Amendment Options. If “No” is indicated, the MOA will not be amended with respect to the particular
Amendment Option.

A.
No]

Option to Amend MOA to Extend Term of MOA and Access to Data – Requested: [Yes or

The Parties hereby mutually agree to amend the expiration date of the referenced MOA such that it shall
remain in full force and effect for an additional period of 180 days from the previously agreed expiration
date of this MOA, noted above. Researcher desires to extend the expiration date of the referenced MOA
in order to extend Researcher’s access to approved datasets under the MOA for that same amount of time
(in other words, access will be allowed until the amended MOA expiration date). Pursuant to this
Amendment, the MOA shall now expire on ______________________.
B.
Option to Amend MOA to Add Additional Persons to the Research Team – Requested: [Yes
or No]
The Parties hereby mutually agree to amend Attachment A of the referenced MOA by supplementing it
with the information contained in Attachment A of this Amendment, which lists additional persons who
will be on the research team and will have access to and use of the approved Data under the MOA. Such
additional persons shall not be allowed access to and use of the Data until such time as this Amendment
has been duly executed by both Parties.
C.

Option to Amend MOA to Delete Persons on the Research Team – Requested: [Yes or No]

The Parties hereby mutually agree to amend Attachment A of the referenced MOA by supplementing it
with the information contained in Attachment A of this Amendment, which lists persons who will no
longer be on the research team and will no longer have access to and use of the approved Data. Upon
execution of this Amendment, such persons will be deleted from the research team and will no longer be
allowed access to or use of the Data.

DHS Form 10060 (4/10)

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OMB # 1640-0012 / Expires 12/31/2013

2.
Attachment A and all other terms and conditions of the referenced MOA shall remain as originally
executed and effective (or as previously amended), subject to the amendments herein.
This Amendment shall not be considered accepted or effective until signed below by the Parties. By signing
below, neither Party may assign all or a portion of its rights and obligations hereunder without the prior written
approval of the other Party.
RESEARCH TRIANGLE INSTITUTE
PREDICT COORDINATING CENTER

PRINCIPAL RESEARCHER

Signature

Signature

Name

Name

Title

Title

Organization

Organization

Date

Date

DHS Form 10060 (4/10)

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OMB # 1640-0012 / Expires 12/31/2013

Attachment A
Additional Persons Who Will Be on Research Team and Have Access to Data:
Name

Organization

Address

Telephone

Email

Telephone

Email

Persons To be Deleted From Research Team:
Name

DHS Form 10060 (4/10)

Organization

Address

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