View Information Collection (IC)

View Information Collection (IC)

IC Title:	Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b	Agency IC Tracking Number:	CMS-R-235

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-235	Form-R-235 DUA	Form-R-0235 DUA.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	Form-R-235A Addendum	Form 0235a Addendum.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	CMS-R-235U	cms-r-0235u.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	CMS-R-235L	CMS-R-0235L oeda.pdf		Yes	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	9,200	0	0	-40	9,240	0
Annual IC Time Burden (Hours)	2,900	0	0	158	2,742	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.