Information Collection

HCUP Application Form

IC 204300 under ICR 201209-0935-003 · OMB 0935-0206.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0206 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 NIS Application HCUP Application Form	Form and Instruction
Form Form #2 KID Application HCUP Application Form	Form and Instruction
Form Form #3 NEDS Application HCUP Application Form	Form and Instruction
Form Form #4 SID & SASD &SEDD Application HCUP Application Form	Form and Instruction
Form #1 NIS Application NIS Application.pdf	Form and Instruction
Form #2 KID Application KID Application.pdf	Form and Instruction
Form #3 NEDS Application NEDS Application.pdf	Form and Instruction
Form #4 SID & SASD &SEDD Application SID & SASD & SEDD Application.pdf	Form and Instruction

IC Title:

HCUP Application Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	Form #1	Yes	Yes	Fillable Fileable
Form and Instruction	Form #2	Yes	Yes	Fillable Fileable
Form and Instruction	Form #3	Yes	Yes	Fillable Fileable
Form and Instruction	Form #4	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	200	200
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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