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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.