CMS-R-235 Collaborator Supplement

RESEARCH IDENTIFIABLE FILE (RIF) REQUEST APPLICATION: COLLABORATING ORGANIZATION SUPPLEMENT
GENERAL INSTRUCTION
Fill out one copy of this Attachment for each collaborating organization identified in the Key Personnel Document.
Requester

Must match the individual specified in the RIF DUA.

Requesting Organization

Must match the organization specified in the RIF DUA.

Study Title

Must match the study title specified in section 3 of the RIF DUA.

Collaborating Organization

Must match the organization name used in section 3 of the Key Personnel Supplement.

Please answer the following questions about access to individually identifiable Medicare beneficiaries and/or Medicaid recipients
(hereinafter referred to as beneficiaries) data and any individually identifiable derivative data that is not compliant with section 5 of
the DUA.
1.

Type of Organization (Collaborating Organization):

2.

How will the collaborating organization access the unaggregated CMS data (secure VPN, a physical copy on site at the
collaborating organization, traveling to the DUA holder’s site, etc.)? If the collaborating organization holds a copy of the data
(in part or in whole), please attach the appropriate DMP SAQ summary report.

3.

Describe the role the collaborating organization will have in this study.

Please check one.
0 Non-profit/Academic
0 For-profit (i.e., participating in CMS’ Innovator Program)
0 State Agency
0 Federal Agency

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