Form 10077 (11/11) 10077 (11/11) Amendment to Research Organization Memorandum of Agreeme

OMB # 1640-0012 / Expires xx/xx/xxxx
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 xx/xx/xxxx. 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 10077 This document is used to:
1. Extend the term of an existing Memorandum of Agreement (MOA) with a Research Organization and
extend access to approved Data covered under the MOA;
2. Add members to the research team under an existing MOA with a Research Organization so they may
have access to and use of the approved Data under the MOA;
3. Delete members of the research team under an existing MOA with a Research Organization; and/or
4. Substitute the Data Custodian named on an existing MOA with a Research Organization with a new
Data Custodian, with the option to cancel the PREDICT account of the Data Custodian being replaced.
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 Postal Code
Country Email
Phone Alt Phone Fax
This document serves as an Amendment to the Memorandum of Agreement (MOA), referenced as MOA
ID __________, between __________________________ (“Research Organization” 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;
C. Delete members of the research team under an existing MOA with a Research Organization; and/or
D. Substitute the Data Custodian named on the referenced MOA with a new Data Custodian, with the
option to cancel the PREDICT account of the Data Custodian being replaced.
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. Option to Amend MOA to Extend Term of MOA and Access to Data – Requested: [Yes or No]
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.
D. Option for Amendment to Substitute Data Custodian – Requested: [Yes or No]
The Parties hereby mutually agree to amend Attachment A of the referenced MOA by replacing the
name of the Data Custodian on the existing MOA to that of the new Data Custodian named in
Attachment A of this Amendment.

The MOA shall remain in effect, subject to any amendments, and the approved members of the research
team shall continue to have access to datasets under this MOA.
If the previous Data Custodian has (i) left the employ of or is no longer affiliated or aligned with the
Research Organization, or (ii) the previous Data Custodian will no longer require access to the PREDICT
data catalog, or (iii) the previous Data Custodian has died, the Research Organization shall notify PCC of
such by marking “Yes” below and the PREDICT account for Data Custodian’s access to the data catalog
shall be closed.
______YES: Cancel PREDICT Account for previous Data Custodian ______ (name)________________.
______ NO: DO NOT cancel PREDICT Account for previous Data Custodian,_____________________.
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 authorized
representatives of both of the Parties, and each Party represents and warrants that the person signing
this Amendment on its behalf has full authority to bind his/her organization. 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
RESEARCH ORGANIZATION
Signature
Name
Title
Organization
Date
Attachment A
Previous Data Custodian:
Name
New Data Custodian:
Name

Title
Organization
Address
Address 2
City State/Province Postal Code
Country Email
Phone Alt Phone Fax
Additional Persons Who Will Be on Research Team and Have Access to Data:
Name Organization Address Telephone Email
Persons to be Deleted from Research Team:
Name Organization Address Telephone Email