Form COD, Certificate of Disposition Instructions
This form contains 57 fields organized into 9 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Certification | ||
| Printed Name | Text |
Enter the printed name of the DUA Requester or Data Custodian certifying the disposition of the data.
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| Signature | Signature |
Provide the signature of the DUA Requester or Data Custodian certifying the disposition of the data.
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| Date | Text |
Enter the date when the form is being completed and signed.
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| Contact Information | ||
| Text |
Enter the email address of the DUA Requester or Data Custodian.
|
|
| Phone | Text |
Enter the phone number of the DUA Requester or Data Custodian.
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| Data Type | ||
| Group1_Physical#20data | RadioButton |
Select this option if the data being disposed of is physical data.
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| Group1_Direct#20access | RadioButton |
Select this option if the data being disposed of is direct access data.
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| Disposition Details | ||
| Disposition_Row_5 | Text |
Enter the disposition statement for the file listed in row 5. This should detail how the file was disposed of or discontinued.
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| Disposition_Row_6 | Text |
Enter the disposition statement for the file listed in row 6. This should detail how the file was disposed of or discontinued.
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| Disposition_Row_7 | Text |
Enter the disposition statement for the file listed in row 7. This should detail how the file was disposed of or discontinued.
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| Disposition_Row_8 | Text |
Enter the disposition statement for the file listed in row 8. This should detail how the file was disposed of or discontinued.
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| Disposition_Row_9 | Text |
Enter the disposition statement for the file listed in row 9. This should detail how the file was disposed of or discontinued.
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| Disposition_Row_10 | Text |
Enter the disposition statement for the file listed in row 10. This should detail how the file was disposed of or discontinued.
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| Disposition_Row_11 | Text |
Enter the disposition statement for the file listed in row 11. This should detail how the file was disposed of or discontinued.
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| Disposition_Row_12 | Text |
Enter the disposition statement for the file listed in row 12. This should detail how the file was disposed of or discontinued.
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| Disposition_Row_13 | Text |
Enter the disposition statement for the file listed in row 13. This should detail how the data was disposed of or discontinued.
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| Disposition_Row_14 | Text |
Enter the disposition statement for the file listed in row 14. This should detail how the data was disposed of or discontinued.
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| Disposition Options | ||
| I am closing the entire DUA and all associated files. (Choose one option below | CheckBox |
Check this box if you are closing the entire DUA and all associated files.
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| I am only closing certain files on the DUA, but leaving the DUA open. (Complete section 2 | CheckBox |
Check this box if you are only closing certain files on the DUA but leaving the DUA open. Complete section 2 if this option is selected.
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| Other - must be preapproved by CMS | CheckBox |
Check this box if you have another disposition option that has been preapproved by CMS.
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| Other – Must be preapproved by CMS. Provide preapproved language below | Text |
Provide the preapproved language for the other disposition option.
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| File Disposition | ||
| Disposition_Row_1 | Text |
Enter the disposition statement for the first file listed.
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| File(s)_Row_1 | Text |
Enter the name of the first file being disposed of.
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| Year(s)_Row_1 | Text |
Enter the year(s) associated with the first file being disposed of.
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| Disposition_Row_2 | Text |
Enter the disposition statement for the second file listed.
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| File(s)_Row_2 | Text |
Enter the name of the second file being disposed of.
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| Year(s)_Row_2 | Text |
Enter the year(s) associated with the second file being disposed of.
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| Disposition_Row_3 | Text |
Enter the disposition statement for the third file listed.
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| File(s)_Row_3 | Text |
Enter the name of the third file being disposed of.
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| Year(s)_Row_3 | Text |
Enter the year(s) associated with the third file being disposed of.
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| Disposition_Row_4 | Text |
Enter the disposition statement for the fourth file listed.
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| File(s)_Row_4 | Text |
Enter the name of the fourth file being disposed of.
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| Year(s)_Row_4 | Text |
Enter the year(s) associated with the fourth file being disposed of.
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| File Information | ||
| File(s)_Row_5 | Text |
Enter the name or identifier of the file being disposed of or discontinued in row 5.
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| Year(s)_Row_5 | Text |
Enter the year(s) associated with the file listed in row 5.
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| File(s)_Row_6 | Text |
Enter the name or identifier of the file being disposed of or discontinued in row 6.
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| Year(s)_Row_6 | Text |
Enter the year(s) associated with the file listed in row 6.
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| File(s)_Row_7 | Text |
Enter the name or identifier of the file being disposed of or discontinued in row 7.
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| Year(s)_Row_7 | Text |
Enter the year(s) associated with the file listed in row 7.
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| File(s)_Row_8 | Text |
Enter the name or identifier of the file being disposed of or discontinued in row 8.
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| Year(s)_Row_8 | Text |
Enter the year(s) associated with the file listed in row 8.
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| File(s)_Row_9 | Text |
Enter the name or identifier of the file being disposed of or discontinued in row 9.
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| Year(s)_Row_9 | Text |
Enter the year(s) associated with the file listed in row 9.
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| File(s)_Row_10 | Text |
Enter the name or identifier of the file being disposed of or discontinued in row 10.
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| Year(s)_Row_10 | Text |
Enter the year(s) associated with the file listed in row 10.
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| File(s)_Row_11 | Text |
Enter the name or identifier of the file being disposed of or discontinued in row 11.
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| Year(s)_Row_11 | Text |
Enter the year(s) associated with the file listed in row 11.
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| File(s)_Row_12 | Text |
Enter the name or identifier of the file being disposed of or discontinued in row 12.
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| Year(s)_Row_12 | Text |
Enter the year(s) associated with the file listed in row 12.
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| File(s)_Row_13 | Text |
Enter the name(s) of the file(s) being disposed of or discontinued in row 13.
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| Year(s)_Row_13 | Text |
Enter the year(s) associated with the file(s) listed in row 13.
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| File(s)_Row_14 | Text |
Enter the name(s) of the file(s) being disposed of or discontinued in row 14.
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| Year(s)_Row_14 | Text |
Enter the year(s) associated with the file(s) listed in row 14.
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| Requester Information | ||
| Requester | Text |
Enter the name of the person requesting the closure or disposition of the CMS data.
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| Requesting Organization | Text |
Enter the name of the organization requesting the closure or disposition of the CMS data.
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| Study Information | ||
| Study Title | Text |
Enter the title of the study associated with the CMS data.
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| DUA Number | Text |
Enter the Data Use Agreement (DUA) number associated with the CMS data.
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