Form COD, Certificate of Disposition Instructions
This form contains 57 fields organized into 19 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Certification | ||
| Signature | Signature |
Provide the signature of the DUA Requester or Data Custodian certifying the disposition of the data.
|
| Data Disposition Options | ||
| Closing entire DUA | Checkbox |
Check this box if you are closing the entire Data Use Agreement (DUA) and all associated files.
|
| Closing certain files on DUA | Checkbox |
Check this box if you are closing only specific files on the Data Use Agreement (DUA), but intend to leave the DUA open.
|
| Other (CMS Preapproved) | Checkbox |
Check this box if your data disposition method is 'Other' and has been preapproved by CMS, requiring you to provide the preapproved language.
|
| Disposition Confirmation | ||
| Printed Name | Text |
Please enter the printed name of the Requester or Data Custodian. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Text |
Please enter the email address of the Requester or Data Custodian. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
|
| Phone Number | Text |
Please enter the phone number of the Requester or Data Custodian. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Date | Date |
Please enter the date of this disposition confirmation. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Eighth File Disposition | ||
| Eighth File Disposition | Text |
Enter the letter (A, B, or C) corresponding to the disposition statement for the eighth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Eighth File Name | Text |
Provide the name or description of the eighth file(s) that have this disposition. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Eighth File Year(s) | Text |
Enter the year or years associated with the eighth file(s). Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Eleventh File Disposition | ||
| Eleventh Disposition | Text |
Please provide the disposition statement letter (A, B, or C) for the eleventh file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Eleventh File Name | Text |
Please provide the name or identifier of the eleventh file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Eleventh File Year | Text |
Please provide the year(s) associated with the eleventh file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Fifth File Disposition | ||
| Disposition Letter (5th File) | Text |
Provide the letter (A, B, or C) that corresponds to the disposition statement for the fifth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| File Name (5th File) | Text |
Provide the name or identifier of the fifth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| File Year(s) (5th File) | Text |
Provide the year or range of years associated with the fifth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| First File Disposition | ||
| Disposition Letter | Text |
Enter the letter (A, B, or C) corresponding to the disposition statement for this file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| File Name | Text |
Provide the name or a brief description of the file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| File Year(s) | Text |
Enter the year or range of years associated with the file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Fourteenth File Disposition | ||
| Fourteenth Disposition Type | Text |
Enter the letter (A, B, or C) corresponding to how the fourteenth file was disposed of. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Fourteenth File Identifier(s) | Text |
Provide the name or identifier for the fourteenth file(s) being disposed of. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Fourteenth File Year(s) | Text |
Enter the year(s) related to the disposition of the fourteenth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Fourth File Disposition | ||
| Fourth File Disposition Type | Text |
Enter the letter (A, B, or C) corresponding to the disposition statement for the fourth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Fourth File Name | Text |
Provide the name or identifier of the fourth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Fourth File Year(s) | Text |
Enter the year or years associated with the fourth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Ninth File Disposition | ||
| Ninth File Disposition Code | Text |
Enter the letter (A, B, or C) that corresponds to the disposition statement for the ninth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Ninth File(s) Identifier | Text |
Provide the name or identifier of the ninth file, including any reuse DUA number if the disposition is B. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Ninth File Year(s) | Text |
Enter the year or years associated with the ninth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Other Disposition Explanation | ||
| Other Disposition Preapproved Language | Text |
Provide the language preapproved by CMS for the 'Other' disposition method. Fill only if 'Other (CMS Preapproved)' is selected.
Depends on:
Other (CMS Preapproved)
|
| Requester Information | ||
| Requester | Text |
Enter the name of the individual requester, ensuring it matches the name specified in the DUA.
|
| Requesting Organization | Text |
Provide the name of the requesting organization, ensuring it matches the organization specified in the DUA.
|
| Study Title | Text |
Input the full title of the study, making sure it matches the study title specified in section 3 of the DUA.
|
| DUA Number | Text |
Enter the Data Use Agreement (DUA) number.
|
| Received Physical Data Files | Radiobutton |
Check this box if you received physical data files and need to complete section 2. Fill only if 'Closing entire DUA' is selected.
Depends on:
Closing entire DUA
|
| No Physical Data, Accessed Via CMS | Radiobutton |
Check this box if you received no physical data and only accessed data through CMS systems, then skip to section 3. Fill only if 'Closing entire DUA' is selected.
Depends on:
Closing entire DUA
|
| Second File Disposition | ||
| Disposition Type | Text |
Enter the letter (A, B, or C) corresponding to the disposition statement for this file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| File Name(s) | Text |
Provide the name(s) of the file(s) being listed for disposition. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Disposition Year(s) | Text |
Enter the year or years associated with the disposition of the file(s). Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Seventh File Disposition | ||
| Disposition Letter | Text |
Enter the letter (A, B, or C) corresponding to the disposition statement for this file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| File Names | Text |
Provide the name(s) or identifier(s) of the file(s) being disposed of. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| File Year(s) | Text |
Enter the year(s) associated with the file(s) listed. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Sixth File Disposition | ||
| Sixth Disposition Letter | Text |
Provide the letter (A, B, or C) corresponding to the disposition statement for the sixth file listed. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Sixth File Description | Text |
Enter the name of the sixth file(s) or the reuse DUA number as applicable. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Sixth Disposition Year(s) | Text |
Provide the year or years associated with the disposition of the sixth file(s). Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Tenth File Disposition | ||
| Tenth Disposition Letter | Text |
Please provide the letter (A, B, or C) indicating the disposition statement for the tenth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Tenth File Name(s) | Text |
Please provide the name(s) of the tenth file(s) for this disposition. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Tenth File Disposition Year(s) | Text |
Please provide the year(s) associated with the disposition of the tenth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Third File Disposition | ||
| Third File Disposition Letter | Text |
Enter the letter (A, B, or C) corresponding to the disposition statement for the third file listed. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Third File Name | Text |
Provide the name or identifier of the third file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Third File Year | Text |
Enter the year(s) associated with the third file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Thirteenth File Disposition | ||
| Thirteenth Disposition Letter | Text |
Specify the letter (A, B, or C) that corresponds to the disposition statement for the thirteenth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Thirteenth File Name(s) | Text |
Provide the name or identifier of the thirteenth file(s) associated with this disposition. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Thirteenth File Year(s) | Text |
Enter the year(s) relevant to the disposition of the thirteenth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Twelfth File Disposition | ||
| Twelfth File Disposition Code | Text |
Please enter the letter (A, B, or C) corresponding to the disposition statement for the twelfth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Twelfth File Name | Text |
Please enter the name or identifier of the twelfth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|
| Twelfth File Disposition Year | Text |
Please enter the year or years associated with the disposition of the twelfth file. Fill only if 'I received physical data files.' is 'Yes'.
Depends on:
Received Physical Data Files
|