Information Collection

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

IC 8408 under ICR 201107-0938-005 · OMB 0938-0734.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-235 CMS-R-235.Tab_2c Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b	Form and Instruction
Form CMS-R-235 CMS-R-235.Tab_2a Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b	Form and Instruction
Form CMS-R-235 CMS-R-235.Tab_2b Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b	Form and Instruction
Form CMS-R-235 CMS-R-235.Tab_2d Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b	Form and Instruction
Form CMS-R-235 CMS-R-235.Tab_2e Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b	Form and Instruction
Form CMS-R-235 CMS-R-235.Tab_2i Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b	Form and Instruction
Form CMS-R-235 CMS-R-235.Tab_2j Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b	Form and Instruction
Form CMS-R-235 CMS-R-235.Tab_2f 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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-235	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-235	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: 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 %

table that charts list of burden
	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

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.

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