VA Form 10-0403a, Data Use Agreement, is the agreement the Veterans Health Administration (VHA), part of the U.S. Department of Veterans Affairs, uses to set the terms under which a requestor may use VHA data. The Principal Data Requestor initials each of items a through m and then signs and dates the form. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the original PDF is published by the VA at va.gov.
Last updated
What is 10-0403a?
VA Form 10-0403a, Data Use Agreement, is the one-page VHA agreement in which a Principal Data Requestor commits to the conditions that apply to data provided by the Veterans Health Administration (VHA), the health care arm of the U.S. Department of Veterans Affairs.
The form lists thirteen terms, items a through m, and the requestor initials each one to show agreement. Together they say that:
- the data is used solely for independent assessment and improvement of care for veterans;
- the people with access are the ones listed in item 7 of the agreement;
- the data is available until the retention date set in the DUA, and must then be destroyed, with written notice to the VHA Program Office;
- administrative, technical and physical safeguards protect confidentiality, and a contractor's compliance with Federal and VA privacy and security requirements is monitored;
- reports, publications and presentations recognize the VHA Program Office as a co-author, unless its Chief declines;
- end products go to the VHA Program Office for review, and entities such as networks, hospitals or clinics are not identified except as the DUA allows;
- non-VA research includes a copy of the IRB approval or exception, and a written description of the study protocol or intended analysis is provided;
- no research funded by non-VA sources uses the data without written approval, and an annual report on use is submitted.
A closing note says that "VHA Program Office and Chief Officer" is read as "VHA Facility or VHA Network Official" when that matches the organizational level of the data holder. The form is dated DEC 2002.
Who needs to file 10-0403a?
The person who signs this agreement is the Principal Data Requestor, the individual who receives data from a VHA Program Office and takes responsibility for its use under the terms printed on the form.
Other parties the form speaks to:
- People with access to the data. They are listed in item 7 of the agreement, unless the agreement is amended.
- Contractors. If a contractor uses the data, the requestor agrees to monitor the contractor's compliance with Federal and VA privacy and security requirements.
- Non-VA researchers. For non-VA research, the requestor provides a copy of the project's IRB approval or IRB exception.
- Data held at a facility or network. Where the data holder is a VHA facility or network, the terms naming the VHA Program Office and its Chief Officer are read as referring to the VHA Facility or VHA Network Official.
The form says that exceptions or non-applicable items are noted on an appended page that is signed and dated. It does not describe any representative signing for the requestor.
When to file 10-0403a
The form sets no due date for itself: the Principal Data Requestor initials and signs it in connection with receiving VHA data, and the terms it contains carry their own timing. The data stays available until the retention date specified in the DUA, and the requestor must destroy it after that date and tell the VHA Program Office in writing. The first annual report on use of the data is due one year from the date of initial data provision, and later reports cover the prior year's use and the uses planned for the coming year. If the agreement needs exceptions, they go on a signed and dated page appended to the form.
Documents you need
- A signed and dated appended page, only if you need to note exceptions or non-applicable items to the terms on the form.
- A copy of the relevant project IRB approval or IRB exception, for non-VA research (item j), provided to the VHA Program Office.
- A written description of the study protocol or intended analysis (item k), provided to the VHA Program Office.
- Written approval from the VHA Program Office, only if the data will be used for any research funded by non-VA sources (item l).
- An annual report on all use of the data during the prior year and uses planned for the coming year (item m); the first is due one year from the date of initial data provision.
- Written notice to the VHA Program Office that the data has been destroyed, after the approved retention date (item f).
How to fill out 10-0403a
Read all thirteen terms
Read items a through m before you initial anything. The form says to initial each item to indicate agreement.
Initial items a through c
Initial the purpose limit (a), the list of people with access in item 7 of the agreement (b) and the retention-date understanding (c).
Initial items d through f
Initial the safeguards (d), the contractor-monitoring term (e) and the destruction-and-written-notice term (f).
Initial items g through i
Initial the co-author recognition term (g), submission of end products for review (h) and the limit on identifying entities (i).
Initial items j through l
Initial the IRB approval or exception term for non-VA research (j), the written study protocol description (k) and the limit on non-VA funded research (l). If an item does not apply, note it on an appended page.
Initial the annual report item
Initial item m, which commits you to an annual report on use of the data. The first report is due one year from the date of initial data provision.
Append a page for exceptions
If you need to note exceptions or non-applicable items, attach a page that is signed and dated. Skip this step if you have none.
Sign and date as requestor
Under the statement that you have read and agree to all terms, conditions and policies, the Principal Data Requestor signs and enters the date.
Review and download the PDF
Check that every item is initialed and the signature and date are present. Download or print the completed PDF from FillingPDF and deliver it as the VHA office providing the data directs.
How to submit 10-0403a
The form prints no mailing address, portal, email or appointment rule, so it names no submission channel of its own. What it does identify is the party the agreement runs to: the VHA Program Office, or, depending on the organizational level of the data holder, the VHA Facility or VHA Network Official. That office receives the written notice of destruction, the study protocol description, the IRB approval or exception for non-VA research, the end products for review and the annual report. Ask the VHA office that is providing the data how it wants the signed agreement delivered. If you append a signed and dated page for exceptions or non-applicable items, send it together with the form. FillingPDF lets you fill out and download the PDF; submission follows the channels set by the VHA office that provides the data.
Common mistakes to avoid
- Leaving any of items a through m without initials; the form says to initial all items to indicate agreement.
- Signing without dating, or leaving the Principal Data Requestor signature line blank.
- Crossing out or ignoring an item instead of appending a signed and dated page that notes the exception or non-applicable item.
- Using the data for research funded by non-VA sources without written approval from the VHA Program Office (item l).
- Omitting the IRB approval or exception copy when the work is non-VA research (item j).
- Identifying networks, hospitals, hospital services or clinics, directly or by linking to outside data, when the DUA does not allow it (item i).
- Keeping the data past the approved retention date or destroying it without written notice to the VHA Program Office (item f).
- Missing the first annual report, due one year from the date of initial data provision (item m).
Frequently asked questions
What is VA Form 10-0403a, the Data Use Agreement?
VA Form 10-0403a is the VHA Data Use Agreement. The Principal Data Requestor initials terms a through m, which cover purpose, safeguards, retention, destruction, review of end products and annual reporting, then signs and dates it. It is issued by the Veterans Health Administration.
Who signs the VHA Data Use Agreement?
The Principal Data Requestor signs and dates the form after initialing all items. The form lists no other signature line. People who will have access to the data are named in item 7 of the agreement rather than signing this form.
Do I have to initial every item on the data use agreement?
Yes. The form says to initial all items to indicate agreement. If an item does not apply or you need an exception, append a page noting it, signed and dated, rather than leaving the item unmarked.
Is an IRB approval required with this data use agreement?
For non-VA research, item j has you provide the VHA Program Office a copy of the project's IRB approval or IRB exception. The form attaches this requirement only to non-VA research.
What reports does the VHA data use agreement require?
Item m requires an annual report to the VHA Program Office on all use of the data during the prior year and the uses planned for the coming year. The first report is due one year from the date of initial data provision.
What happens to the data when the retention period ends?
You destroy the data after the approved retention date and notify the VHA Program Office of the destruction in writing (item f). The retention date is the one specified in the DUA.
Where do I send VA Form 10-0403a?
The form prints no address or portal. It runs to the VHA Program Office, or to the VHA Facility or VHA Network Official when the data holder is at that level, so ask the VHA office providing the data how to deliver the signed form.
Can I fill out the Data Use Agreement online on FillingPDF?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not submit the agreement to the VA; delivery follows the instructions of the VHA office providing the data.
Ready to fill out 10-0403a?
Fill out 10-0403a now