Track Change - RIF Amendment

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

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CMS Approver Signature:

Notes:

GENERAL INSTRUCTIONS
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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

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
Data File Name
Years/Quarters Requested 1
EPPE Code

Cohort

DUA #
(reuse
only)

Dissemination

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☐ 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
Data File Name
Justification for how each data
Years/Quarters
EPPE Code
file will be used in the analysis
Requested 2

1
2

Cohort

DUA #
(reuse
only)

Dissemination

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

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

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RESEARCH IDENTIFIABLE FILE (RIF) DATA USE AGREEMENT: AMENDMENT REQUEST
☐ 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].
☐ Project Fee Renewal
☐ CCW VRDC Add-ons
☐ 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/remove 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

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

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