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⚠️ Notice: This information collection may be referencing outdated material.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 CMS-R-235.Tab_2c CMS-R-235.Tab_2c_Draft.pdf Form and Instruction
CMS-R-235 CMS-R-235.Tab_2a CMS-R-235.Tab_2a_Draft.pdf Form and Instruction
CMS-R-235 CMS-R-235.Tab_2b CMS-R-235.Tab_2b_Draft.pdf Form and Instruction
CMS-R-235 CMS-R-235.Tab_2d CMS-R-235.Tab_2d_Draft.pdf Form and Instruction
CMS-R-235 CMS-R-235.Tab_2e CMS-R-235.Tab_2e_Draft.pdf Form and Instruction
CMS-R-235 CMS-R-235.Tab_2i CMS-R-235.Tab_2i_Draft.pdf Form and Instruction
CMS-R-235 CMS-R-235.Tab_2j CMS-R-235.Tab_2j_Draft.pdf Form and Instruction
CMS-R-235 CMS-R-235.Tab_2f CMS-R-235.Tab_2f_Draft.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: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-235	CMS-R-235.Tab_2c	CMS-R-235.Tab_2c_Draft.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	CMS-R-235.Tab_2a	CMS-R-235.Tab_2a_Draft.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	CMS-R-235.Tab_2b	CMS-R-235.Tab_2b_Draft.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	CMS-R-235.Tab_2d	CMS-R-235.Tab_2d_Draft.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	CMS-R-235.Tab_2e	CMS-R-235.Tab_2e_Draft.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	CMS-R-235.Tab_2i	CMS-R-235.Tab_2i_Draft.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	CMS-R-235.Tab_2j	CMS-R-235.Tab_2j_Draft.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	CMS-R-235.Tab_2f	CMS-R-235.Tab_2f_Draft.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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,200	2,200
Annual IC Time Burden (Hours)	1,100	1,100
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.