Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b

Data Use Agreement (DUA) Form (CMS-R-235)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0734 can be found here:

Documents and Forms

Document Name Document Type
Form R-0235a Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b Form and Instruction
R-0235 DUA Form-R-0235 DUA Form-R-0235 DUA.pdf Form and Instruction
R-0235a Form 0235a Addendum Form 0235a Addendum.pdf Form and Instruction
R-0235L CMS-R-0235L oeda CMS-R-0235L oeda.pdf Form and Instruction
R-0235u. cms-r-0235u cms-r-0235u.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Data Use Agreement Information Collection Requirements, Model Language, and Supporting Regulations in 45 CFR Section 5b	Agency IC Tracking Number:	CM-CPC

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	R-0235a	Form 0235a Addendum	Form 0235a Addendum.pdf	Yes	No	Fillable Printable
Form and Instruction	R-0235 DUA	Form-R-0235 DUA	Form-R-0235 DUA.pdf	Yes	No	Fillable Printable
Form and Instruction	R-0235L	CMS-R-0235L oeda	CMS-R-0235L oeda.pdf	Yes	No	Fillable Printable
Form and Instruction	R-0235u.	cms-r-0235u	cms-r-0235u.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	9,200	-40	9,240
Annual IC Time Burden (Hours)	2,900	158	2,742
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.