Form R-0235a Form 0235a Addendum

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0734

DATA USE AGREEMENT (DUA) SIGNATURE ADDENDUM FOR DATA ACQUIRED
FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
Please complete this form, if you are adding or updating contact information for a:
• Requestor: The person authorized to legally bind their organization to the terms specified in the DUA. Please
note there can only be one Requestor on each DUA.
• Custodian: Individual(s) who will have actual possession of the CMS data files, and who will be responsible for
observance of all conditions of use, including the establishment and maintenance of security arrangements to
prevent unauthorized use. Please note, CMS requires at least one custodian per organization, exceptions include:
• All individuals that require DESY/IDR or CCW VRDC access need to be listed as Custodians on the DUA
• All individuals to which data will be shipped need to be listed as Custodians on the DUA
• Individuals from the contractor organization who will be submitting DUA changes through their CMS
COR need to be listed on the DUA
• All individuals who will have direct, unsupervised access (on site or VPN) to raw data, analytic files, or
output with cell sizes less than 11 need to be listed as Custodians on the DUA.
• Subcontracting/Collaborating Organization: These are organizations that work with the Requesting
organization but do not have possession of the data. For these organizations we do not add individual users to
the DUA. We only add the organization information itself. (If you are accessing the data via CCW VRDC, DESY, IDR,
VPN, or directly on site please add the individual as a Custodian.)
Important Notes:
• We do not accept P.O. Boxes for an address.
• We do not accept personal e-mail addresses (@yahoo, @gmail, @outlook, etc.). Your e-mail must be associated
with your employer, organization, or university.

DUA Number:
User Role:

Project Name:
Do you need this data shipped directly to you, from CMS?

Will you access this data via the DESY/IDR system?*
Name:

If yes, what is your EUA User ID:
Ext.:

Phone:

Organization:
Street Address:
City:
Email:

State:

Zip:

Signature:_________________________________

*Please note the DESY/IDR option is for Contractor DUAs only.

If applicable, your Contracting Officer Representative (COR)/Government Task Lead (GTL).
Name:

Signature:

_________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0734. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Md. 21244-1850.
Form CMS-R-0235A (06/12)