HCUP Application Form

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⚠️ Notice: This information collection may be referencing outdated material.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 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

Information Collection (IC) Details

IC Title:	HCUP Application Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 Application	NIS Application.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Form #2	KID Application	KID Application.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Form #3	NEDS Application	NEDS Application.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Form #4	SID & SASD &SEDD Application	SID & SASD & SEDD Application.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,300	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	Previously Approved
Annual Number of Responses for this IC	1,300	100	1,200
Annual IC Time Burden (Hours)	217	17	200
Annual IC Cost Burden (Dollars)	0	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.