Online Application Order Form for Products from the Healthcare Cost and Utilization Project (HCUP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #6 SEDD Data Use Agreement	Form and Instruction	New	Available
Form Form #5 SASD Data Use Agreement	Form and Instruction	New	Available
Form Form #4 SID Data Use Agreement	Form and Instruction	New	Available
Form Form #3 NEDS Data Use Agreement	Form and Instruction	New	Available
Form Form #2 KID Data Use Agreement	Form and Instruction	New	Available
Form Form #1 NIS Data Use Agreement	Form and Instruction	New	Available
Form Form #1 HCUP Data Use Agreement Training	Form and Instruction	New	Available
Form Form #4 SID & SASD &SEDD Application	Form and Instruction	New	Available
Form Form #3 NEDS Application	Form and Instruction	New	Available
Form Form #2 KID Application	Form and Instruction	New	Available
Form Form #1 NIS Application	Form and Instruction	New	Available
Attachment A -- Federal Register Notice -- HCUP Online Application Form.pdf	Supplementary Document	Uploaded 2012-09-25	Available
Supporting Statement Part A -- HCUP Online Application Form 6-12-2012.doc	Supporting Statement A	Uploaded 2012-09-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
204302	HCUP DUA	Form and Instruction	New	SEDD Data Use Agreement
204302	HCUP DUA	Form and Instruction	New	SASD Data Use Agreement
204302	HCUP DUA	Form and Instruction	New	SID Data Use Agreement
204302	HCUP DUA	Form and Instruction	New	NEDS Data Use Agreement
204302	HCUP DUA	Form and Instruction	New	KID Data Use Agreement
204302	HCUP DUA	Form and Instruction	New	NIS Data Use Agreement
204301	HCUP DUA Training	Form and Instruction	New	HCUP Data Use Agreement Training
204300	HCUP Application Form	Form and Instruction	New	SID & SASD &SEDD Application
204300	HCUP Application Form	Form and Instruction	New	NEDS Application
204300	HCUP Application Form	Form and Instruction	New	KID Application
204300	HCUP Application Form	Form and Instruction	New	NIS Application

ICR Details

OMB Control No: 0935-0206	ICR Reference No: 201209-0935-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Online Application Order Form for Products from the Healthcare Cost and Utilization Project (HCUP)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/26/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/27/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved
Responses	3,600	0	0
Time Burden (Hours)	600	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: To support AHRQ's mission to improve health care through scientific research, HCUP databases and software tools are disseminated to users outside of the Agency through a mechanism known as the HCUP Central Distributor. The HCUP Central Distributor assists qualified researchers to access uniform research data across multiple states with the use of one application process. The HCUP databases disseminated through the Central distributor are referred to as "restricted access public release files"; that is, they are publicly available, but only under restricted conditions. This information collection request is for the activities associated with the HCUP database application process not the collection of health care data for HCUP databases.

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Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 38292	06/27/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 58383	09/20/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
HCUP Application Form	Form #2, Form #1, Form #3, Form #4	NIS Application ,   KID Application ,   NEDS Application ,   SID & SASD &SEDD Application
HCUP DUA	Form #1, Form #2, Form #3, Form #4, Form #5, Form #6	NIS Data Use Agreement ,   KID Data Use Agreement ,   NEDS Data Use Agreement ,   SID Data Use Agreement ,   SASD Data Use Agreement ,   SEDD Data Use Agreement
HCUP DUA Training	Form #1	HCUP Data Use Agreement Training

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,600	0	0	3,600	0	0
Annual Time Burden (Hours)	600	0	0	600	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $17,237

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/27/2012

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