Contractor Signature Addendum_JobAid

Instructions for completing the Contractor DUA Signature
Addendum
This document: All Data Use Agreement (DUA) requests must include a completed DUA Signature
Addendum if adding a data user on a DUA.

General Instructions
1.
2.
3.

Answer every item in the document.
Do not alter the layout or content of the document.
Upload a signed copy of the DUA Signature Addendum to EPPE.

Specific Instructions

A
The DUA number is generated in EPPE
when the DUA is created. Enter your
DUA number if completing this form for
an amendment request. If submitting a
new request, leave blank.

B

Enter the exact Study Title/Project
Name.

C
Select your user role from the dropdown menu. The definitions of the
role are listed on the form.

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

Contractor 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 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:

State:

Zip:

Email:

(Instructions continue on page 2)

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 Contractor DUA Signature

D

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

Select the data system you are
accessing.

E

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

F

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

Contractor 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 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

The contact signs the document here.
CMS prefers digital signatures on this
form.
Instructions for completing the Contractor DUA Signature

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: