NDTR Signature Addendum_JobAid

Instructions for completing the NDTR Signature Addendum
This document: All Non DUA Tracking (NDTR) requests must include a completed NDTR Signature Addendum
if adding a data user.

General Instructions
1.
2.
3.

Complete every item in the document.
Do not alter the layout or content of the document.
Submit this form to the Data Use Agreement mailbox ..

Specific Instructions

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

B

Enter the exact Project Name.

C

Select your user role from the dropdown menu.

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

Non-Research Purpose (NDTR) 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 Custodian: Individual who will be responsible for ensuring that the environment in which the CMS data is stored
complies all applicable CMS data security requirements, including the establishment and maintenance of security
arrangements to prevent unauthorized use. Please note, CMS requires only one data custodian per data
environment.
• Data Recipient: An individual under the oversight of the Data Custodian that will receive physical shipment or virtual
download of CMS data.
• Direct Access User: An individual that will have direct access to CMS data through CMS systems. This includes CCW VRDC
seat holders.
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 NDTR.
• 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.

NDTR Number:

A

Data System (for direct access users only):

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:

Instructions for completing the DUA Signature Addendum | page 1

D

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

Select the data system you are
accessing.

E

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

F

Enter the name of the contact being
added.

Non-Research Purpose (NDTR) 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 Custodian: Individual who will be responsible for ensuring that the environment in which the CMS data is stored
complies all applicable CMS data security requirements, including the establishment and maintenance of security
arrangements to prevent unauthorized use. Please note, CMS requires only one data custodian per data
environment.
• Data Recipient: An individual under the oversight of the Data Custodian that will receive physical shipment or virtual
download of CMS data.
• Direct Access User: An individual that will have direct access to CMS data through CMS systems. This includes CCW VRDC
seat holders.
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 of America.

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 the physical address for the contact. CMS will not accept PO boxes,
residential addresses or foreign
addresses.

J

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

K

Please Sign here.
Instructions for completing the DUA Signature Addendum | page 2

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: