CMS-R-235 Key Personnel Supplement

RESEARCH IDENTIFIABLE FILE (RIF) REQUEST APPLICATION: KEY PERSONNEL SUPPLEMENT
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.

IDENTIFY THE KEY PERSONNEL
1.

Requester Contact Information:
The Requester is the person authorized to legally bind their organization to the terms specified in the DUA. Per CMS
requirements, there must only be one Requester on each DUA.
Email

Phone Number

Organization Address
2.

Collaborating Organizations (If applicable):
A Collaborating Organization is an organization that works with the requesting organization, is involved in the research, and is
viewing or accessing unaggregated data. Collaborators that are only accessing aggregated and de-identified results that meet
the cell suppression policy outlined in section 5 of the CMS DUA should not be listed.
Will this this study have a collaborating organization(s)?
If yes, please list the organization(s) in the following table and complete a Collaborating Organization Supplement.
Organization Name
Organization Address
Organization Name
Organization Address

Organization Name
Organization Address

1

RESEARCH IDENTIFIABLE FILE (RIF) REQUEST APPLICATION: KEY PERSONNEL SUPPLEMENT
3.

Additional Contact(s):
An Additional Contact is an individual that is involved in the research study. An individual listed as an additional contact will
receive notifications about the DUA and will be able to perform certain DUA functions.
Name of Additional Contact
Email

Phone Number

Organization

Collaborator

Name of Additional Contact
Email

Phone Number

Organization

Collaborator

Name of Additional Contact
Email

Phone Number

Organization

Collaborator

Name of Additional Contact
Email
Organization

Phone Number
Collaborator

2