Information Collection

Uniform Data System

IC 6420 under ICR 201312-0915-002 · OMB 0915-0193.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0193 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 UDS Manual Uniform Data System	Form and Instruction
Form T7 T7 Uniform Data System	Form and Instruction
Form T6A T6A Uniform Data System	Form and Instruction
Form App D App D Uniform Data System	Form and Instruction
Form T4 T4 Uniform Data System	Form and Instruction
Form T6B T6B Uniform Data System	Form and Instruction
Form 1 2014 Tables Uniform Data System	Form and Instruction
Form 2 EHR Question Uniform Data System	Form and Instruction
1 UDS Manual UDS Manual 2012 V 25 with proposed 2013 changesCDHN.doc	Form and Instruction
T7 T7 T7.doc	Form and Instruction
T6A T6A T6A.doc	Form and Instruction
App D App D APPENDIX D 2012_ELCD 92513.docx	Form and Instruction
T4 T4 T4.doc	Form and Instruction
T6B T6B T6B.doc	Form and Instruction
1 2014 Tables UDSTables2014_draft.docx	Form and Instruction
2 EHR Question EHR Ques ATTACHMENT 121113.docx	Form and Instruction

IC Title:

Uniform Data System

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 51c 42 CFR 56 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Yes	Yes	Fillable Fileable
Form and Instruction	T7	Yes	Yes	Fillable Fileable
Form and Instruction	T6A	Yes	Yes	Fillable Fileable
Form and Instruction	App D	Yes	Yes	Fillable Fileable
Form and Instruction	T4	Yes	Yes	Fillable Fileable
Form and Instruction	T6B	Yes	Yes	Fillable Fileable
Form and Instruction	1	Yes	Yes	Fillable Fileable
Form and Instruction	2	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,287

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,287	1,287
Annual IC Time Burden (Hours)	111,438	111,438
Annual IC Cost Burden (Dollars)	254,826	254,826

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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