CMS-R-235 Amendment Request Form

Research Identifiable File (RIF) Data USE Agreement: Amendment Request

For CMS Use Only
Amendment Approval Date:	CMS Approver Signature:
Notes:

GENERAL INSTRUCTIONS

• At the onset of your request, please only provide an unsigned, draft document in Word format

• Additional supporting documents may be needed for amendments, please visit ResDAC’s website for information on required documentation at the following link: https://www.resdac.org/managing-your-project-after-obtaining-data

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
DUA #

REQUESTED ACTION(S) TO AMEND THIS DUA (CHECK ALL THAT APPLY):

☐ I am requesting the same data files with the same cohort for the same project, but data for the most recent quarters/years, specifically the following:

Add rows to the table as needed by clicking on the ‘+’ in the lower right of the table.

Data File Name	Years/Quarters Requested1	Cohort	DUA # (reuse only)	Dissemination

☐ I am requesting data files that have not been previously covered under this DUA, specifically the following:

Add rows to the table as needed by clicking on the ‘+’ in the lower right of the table.

Data File Name	Justification for how each data file will be used in the analysis	Years/Quarters Requested2	Cohort	DUA # (reuse only)	Dissemination

☐ I am requesting another type of modification (e.g. study objectives/aims, linkage of CMS data to non-CMS data, etc.) of the Attachment A - RIF Application.

☐ I am requesting a change related to VRDC access:

☐ Seat Extension: [Enter # of Seats & qtrs./1yr.]

☐ Seat Addition: [Enter # of Seats]

☐ Seat Transfer: Please transfer the seat currently held by [Enter original seat holder] to [Enter new seat holder].

☐ Project Fee Renewal

☐ VRDC Cloud Add-on

☐ I am requesting to change the funding source for the DUA to the following:

☐ Non-profit/Academic

☐ For-profit

☐ State Agency

☐ Federal Agency/Federal Agency Grant – [Insert Federal Agency Name]

☐ I am requesting to add a collaborating organization.

☐ I am requesting to change the Requester on this DUA.

☐ I am requesting a type of amendment not listed above.

Please describe the requested amendment in the text box below.

The amendment(s) requested above modify the materials approved for the DUA # listed above and therefore are incorporated by reference into this DUA.

The undersigned individual hereby attests that he or she is authorized to amend the DUA# listed above on behalf of the Requesting Organization and agrees to all the terms specified in the DUA.

Requester Signature Date

Requester Printed Name

1 Please refer to the ResDAC website for information on data file availability.

2 Please refer to the ResDAC website for information on data file availability.

4