RIF Signature Addendum_JobAid

Instructions for completing the Research Identifiable File
(RIF) DUA Signature Addendum
This document: All Data Use Agreement (DUA) requests must include a completed DUA Signature
Addendum if adding or replacing a data user on a DUA.

Note: This form is used when adding a VRDC seat holder. Data Custodians on a RIF DUA need to reach out to the
Data Privacy Security Program (DPSP) to change the custodian through the Data Management Plan SelfAttestation Questionnaire (DMP SAQ) process.

General Instructions
1.
2.
3.

Answer every item in the document.
Do not alter the layout or content of the document.
Submit to ResDAC an unsigned, editable draft in PDF format.

Specific Instructions

A

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

Enter your DUA number if completing
this form for an amendment request. If
submitting a new request, leave blank.

Research Identifiable File (RIF) DATA USE AGREEMENT (DUA) SIGNATURE
ADDENDUM FOR DATA ACQUIRED FROM THE CENTERS FOR
MEDICARE & MEDICAID SERVICES (CMS)

B

Complete this form if you are adding one of the following users to the data use agreement:
• Data Recipient: An individual under the oversight of the Data Custodian that will receive physical shipment or virtual
download of CMS data.
• VRDC Seat Holder: An individual that will have direct access to CMS data through the Chronic Conditions Warehouse
(CCW) Virtual Research Data Center (VRDC).

Enter the exact Study Title listed on
the DUA if completing this form for an
amendment request. If submitting a
new request, enter the exact Study Title
listed on Attachment A: RIF Application.

C
Select your user role from the dropdown menu.

Important Notes:
• All form fields are required.
• CMS does not require this form for updates to existing Requester or Data Custodian contact information (e.g., e-mail
address, phone numbers), but only to add an individual who is not already on the DUA.
• CMS does not accept mailbox rental services (P.O. Box, UPS Store, etc.) for an address.
• CMS does not accept foreign addresses outside of the United States and its territories.
• CMS does not accept personal e-mail addresses (@yahoo, @gmail, @outlook, etc.). Your e-mail must be associated
with your employer, organization, or university.
• All CMS data must physically remain within the boundaries of the United States and its territories.

DUA Number:

A

Data System (for direct access users only):
Name:

:

If Other, please enter:
Phone:

G

Ext.:

Organization:
Street Address:
City:
Email:

Instructions for completing the RIF DUA Signature Addendum | page

State:

Zip:

By signing this form, you are attesting to the terms and conditions defined in the original Data Use Agreement (DUA) documentation.

Signature:

Instructions for completing the RIF DUA Signature Addendum | page

D

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

Select the data system you are accessing
from the drop-down menu. If you are a direct
access user submitting an addendum for a
researcher DUA, select ‘CCW VRDC’. For RIF
DUAs, this only applies to VRDC seat holders.

E

If accessing a different data system
other than the options provided, enter
here.

F

Enter the name of the contact being
added to the DUA.

Research Identifiable File (RIF) DATA USE AGREEMENT (DUA) SIGNATURE
ADDENDUM FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE
& MEDICAID SERVICES (CMS)
Complete this form if you are adding one of the following users to the data use agreement:
• Data Recipient: An individual under the oversight of the Data Custodian that will receive physical shipment or virtual
download of CMS data.
• VRDC Seat Holder: An individual that will have direct access to CMS data through the Chronic Conditions Warehouse
(CCW) Virtual Research Data Center (VRDC).
Important Notes:
• All form fields are required.
• CMS does not require this form for updates to existing Requester or Data Custodian contact information (e.g., e-mail
address, phone numbers), but only to add an individual who is not already on the DUA.
• CMS does not accept mailbox rental services (P.O. Box, UPS Store, etc.) for an address.
• CMS does not accept foreign addresses outside of the United States and its territories.
• CMS does not accept personal e-mail addresses (@yahoo, @gmail, @outlook, etc.). Your e-mail must be associated
with your employer, organization, or university.
• All CMS data must physically remain within the boundaries of the United States and its territories.

DUA Number:

A

Data System (for direct access users only):

G
H

Enter the contact’s phone number.

Enter the exact legal name of the contact’s organization.

I

Enter a physical address for the contact. CMS will not accept a PO box or
foreign address.

J

Enter the contact’s email address associated with an employer, organization, or university. CMS will not accept
personal email addresses (e.g.,
gmail.com or hotmail.com).

K

When directed by ResDAC, the contact
signs the document here.
Instructions for completing the RIF DUA Signature Addendum | page

Name:

:

If Other, please enter:
Phone:

G

Ext.:

Organization:
Street Address:
City:

State:

Zip:

Email:

By signing this form, you are attesting to the terms and conditions defined in the original Data Use Agreement (DUA) documentation.

Signature: