Information Collection

Certificate of Data Destruction for Data Acquired from the Centers for Medicare and Medicaid Services

IC 184090 under ICR 201107-0938-004 · OMB 0938-1046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1046 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10252 Certificate of Data Destruction for Data Acquired from the Centers for Medicare and Medicaid Services Form and Instruction
CMS-10252 CMS-10252. Draft Revised DUA CMS-10252. Draft Revised DUA.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certificate of Data Destruction for Data Acquired from the Centers for Medicare and Medicaid Services	Agency IC Tracking Number:

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-10252	CMS-10252. Draft Revised DUA	CMS-10252. Draft Revised DUA.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	84	84
Annual IC Cost Burden (Dollars)	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.