RIF Amendment_JobAid

Instructions for completing the RIF Data Use Agreement:
Amendment Request

This document: This document is used for people requesting to make an amendment, update or change
to an existing Data Use Agreement (DUA). It collects the information needed to describe the nature of the
requested change. Note: Additional supporting documents may be needed for amendment requests. See
ResDAC’s website for information on required documentation.
General Instructions
Answer every item in the document.
Do not alter the layout or content of the document.
The DUA is not finalized/signed until end of ResDAC review progress. Do not sign until directed by ResDAC.
Submit to ResDAC in Word format.

AF
T

1.
2.
3.
4.

Specific Instructions

A

RESEARCH IDENTIFIABLE FILE (RIF) DATA USE AGREEMENT: AMENDMENT REQUEST

B

Enter the exact legal name of the Requesting Organization listed on the RIF
DUA in section 1.

D

C

For CMS Use Only

Amendment Approval Date:

Enter the exact Study Title listed on the
RIF DUA in section 3.

D

Enter the DUA number. It must match the
original.

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
DUA Requester

A

Requesting Organization

B

Study Title

C

DUA #

D

Must match the individual specified in the RIF DUA.

Must match the organization specified in the RIF DUA.

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

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

E

☐ 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:

F

Add rows to the table as needed by clicking on the ‘+’ in the lower right of the table.
Data File
Data File Name
Years/Quarters Requested1
EPPE Code

G

H

I

Cohort

DUA #
(reuse
only)

J

K

Dissemination

L

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

F

Add rows to the table as needed by clicking on the ‘+’ in the lower right of the table.
Data File
Data File Name
Justification for how each data
Years/Quarters
EPPE Code
file will be used in the analysis
Requested2

G

H

M

I

Cohort

J

DUA #
(reuse
only)

K

Dissemination

L



E

☐ 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 CCW 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].

Check all boxes that apply. At least one
box must be checked.
1

(Instructions continue on page 2)

CMS Approver Signature:

Notes:

R

Enter the name of the Requester listed
on the Research Identifiable File (RIF)
DUA. The Requester is the individual authorized to sign agreements on
behalf of the requesting organization.
This person is often referred to as the
‘legal signatory’. This person accepts all
terms and conditions in the DUA and
attests that all information contained in
the request is accurate.

2

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

Instructions for completing the RIF Data Use Agreement: Amendment Request | page 1

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F

RESEARCH IDENTIFIABLE FILE (RIF) DATA USE AGREEMENT: AMENDMENT REQUEST

Each row must only contain a single
combination of exact file name, cohort
and DUA. If a request has more than one
combination for a specific file name,
each needs to be a separate row. If
additional rows are needed, click in the
last row of the table, then on the ‘+’ in
the lower right area of the table. The
contents of this table must be consistent
with the specification worksheet.

G

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

A

Requesting Organization

B

Study Title

C

DUA #

D

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

E

AF
T

☐ 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:

F

Add rows to the table as needed by clicking on the ‘+’ in the lower right of the table.
Data File
Data File Name
Years/Quarters Requested1
EPPE Code

G

H

I

Cohort

J

DUA #
(reuse
only)

K

Dissemination

L

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

F

Add rows to the table as needed by clicking on the ‘+’ in the lower right of the table.
Data File
Data File Name
Justification for how each data
Years/Quarters
EPPE Code
file will be used in the analysis
Requested2

G

H

M

I

Cohort

J

DUA #
(reuse
only)

K

Dissemination

L



☐ 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 CCW 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].

R

Insert the years/quarters of data currently being requested. Do not add
years/quarters of data you already hold
(even from a prior amendment) or future data that is not currently available.

1
2

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

D

J

DUA Requester

Must match the individual specified in the RIF DUA.

Insert the full file name. Only include
one file name per row.

I

CMS Approver Signature:

Notes:

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

Insert the data file EPPE code. Data file
EPPE codes can be found on the RIF
specifications worksheet or on the final
reuse DUA found in the EPPE system/
your internal documentation. If you are
unable to locate the EPPE codes from
these sources, please contact ResDAC.

H

For CMS Use Only
Amendment Approval Date:

In the dropdown, select whether the
data are a % cohort, such as a 5%, 20%,
100% or custom cohort.

K

If reusing data, enter the DUA number
you are reusing from. Otherwise, leave
blank.

(Instructions continue on page 3)

Instructions for completing the RIF Data Use Agreement: Amendment Request | page 2

OMB No. 0938-0734. Exp. 10/31/2025

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L

RESEARCH IDENTIFIABLE FILE (RIF) DATA USE AGREEMENT: AMENDMENT REQUEST
For CMS Use Only

In the dropdown, select whether you
will receive physical data or use the
VRDC.

M

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

If you checked the box indicating you
are requesting new files, describe how
the file will be used in your study in one
to two sentences.

DUA Requester

A

Requesting Organization

B

Study Title

C

DUA #

D

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

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

E

AF
T

☐ 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:

F

Add rows to the table as needed by clicking on the ‘+’ in the lower right of the table.
Data File
Data File Name
Years/Quarters Requested1
EPPE Code

G

H

I

Cohort

J

DUA #
(reuse
only)

K

Dissemination

L

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

F

Add rows to the table as needed by clicking on the ‘+’ in the lower right of the table.
Data File
Data File Name
Justification for how each data
Years/Quarters
EPPE Code
file will be used in the analysis
Requested2

G

H

M

I

Cohort

J

DUA #
(reuse
only)

K

Dissemination

L



☐ 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.

R

☐ I am requesting a change related to CCW 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].

1

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

D

2

Instructions for completing the RIF Data Use Agreement: Amendment Request | page 3

OMB No. 0938-0734. Exp. 10/31/2025

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N

RESEARCH IDENTIFIABLE FILE (RIF) DATA USE AGREEMENT: AMENDMENT REQUEST

If you check this box, also check at
least one sub-box for action type.

O

☐ 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.

N ☐ I am requesting a change related to CCW 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 Add-ons

If requesting an amendment not listed above, add one to three sentences
describing the requested change.

☐ I am requesting to add/remove a collaborating organization.
☐ I am requesting to change the Requester on this DUA.

P

☐ I am requesting a type of amendment not listed above.
Please describe the requested amendment in the text box below.

Submit draft only - do not sign until
directed by ResDAC.

AF
T

Q

O

Enter the name of the Requester
listed above.

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.

P

Requester Signature

Date

Q

D

R

Requester Printed Name

Instructions for completing the RIF Data Use Agreement: Amendment Request | page 4

OMB No. 0938-0734. Exp. 10/31/2025

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