Information Collection

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

IC 8408 under ICR 201911-0938-001 · OMB 0938-0734.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.