Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0734 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-R-235 Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b Form and Instruction
CMS-R-235 Data Use Agreement CMS-R-235.REVISED Instrument.pdf Form and Instruction

Information Collection (IC) Details

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:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	Data Use Agreement	CMS-R-235.REVISED Instrument.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,200	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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,200	700	1,500
Annual IC Time Burden (Hours)	1,100	350	750
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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