Hcup Dua

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form Form #1 HCUP DUA Form and Instruction
Form #1 NIS Data Use Agreement NIS Data Use Agreement.docx Form and Instruction
Form #2 KID Data Use Agreement KID Data Use Agreement.docx Form and Instruction
Form #3 NEDS Data Use Agreement NEDS Data Use Agreement.docx Form and Instruction
Form #4 SID Data Use Agreement SID Data Use Agreement.docx Form and Instruction
Form #5 SASD Data Use Agreement SASD Data Use Agreement.docx Form and Instruction
Form #6 SEDD Data Use Agreement SEDD Data Use Agreement.docx Form and Instruction

Information Collection (IC) Details

IC Title:	HCUP DUA	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	NIS Data Use Agreement	NIS Data Use Agreement.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #2	KID Data Use Agreement	KID Data Use Agreement.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #3	NEDS Data Use Agreement	NEDS Data Use Agreement.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #4	SID Data Use Agreement	SID Data Use Agreement.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #5	SASD Data Use Agreement	SASD Data Use Agreement.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #6	SEDD Data Use Agreement	SEDD Data Use Agreement.docx	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	100	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.