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Templates

Submit completed templates to DSA Mail.

Data Sharing Agreement Application (DSAA). Submit a DSAA in order to request a DSA for systems managed by the Defense Health Agency.

Data Request Templates (DRTs) are provided to help requestors specify the data they seek for a specific use. Attach a DRT for each system listed in the “Source and Type of Data” Section of the DSAA. Choose from the DRTs listed below. Each DRT includes instructions and a sample.

Note: The DRT is required unless otherwise determined by the DHA Privacy Office.  

DRT Quick Reference Guide

De-Identification Plan (DE-ID) Template. Completion of a DE-ID Plan is required when using Expert or Combination Determination to de-identify PHI in accordance to HIPAA regulations. The plan should show how MHS sensitive data elements will be de-identified, as well as, how the HIPAA 18 identifiers will be handled.

HIPAA Safeguard Review of Non-Federal Systems (HSR)Submit an HSR when data will be stored, transmitted, processed, or otherwise maintained on a non-federal information system.

If you are renewing your executed DSA and previously submitted an SSV, you will also need to have the SSV renewed. Please include a copy of the SSV Renewal Template with your DSA Renewal Request.

Change of Government SponsorSubmit a Change of Government Sponsor to document a new Sponsor for the DSA.

Change of Applicant/Recipient. Submit a Change of Applicant/Recipient to document a new Applicant/Recipient for the DSA.

Modification Request. Submit a Modification Request to document any changes to the information provided in the DSAA of an existing DSA.

Extension RequestSubmit an Extension Request to request a 30 day extension of an existing DSA.

Renewal Request. Submit a Renewal Request to renew an existing DSA.

Certification of Data Disposition (CDD). Submit a CDD within 30 days of the expiration of a DSA or the end of the project, whichever comes first, to certify that the data used in connection with the DSA was appropriately disposed.

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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