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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

System Security Verification (SSV). Submit an SSV when data will be stored, processed, maintained, or used on equipment that is not DoD approved (e.g. contractor, academic institution equipment).

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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