Data Management Plan Self-Attestation Questionnaire (DMPSAQ) (CMS-10733)

ICR 202102-0938-011


Federal Form Document

Forms and Documents
IC Document Collections
ICR Details
Received in OIRA
Data Management Plan Self-Attestation Questionnaire (DMPSAQ) (CMS-10733)
Existing collection in use without an OMB Control Number   No
Regular 02/19/2021
  Requested Previously Approved
36 Months From Approved
1,000 0
1,500 0
0 0

The Privacy Act of 1974, §552a requires the Centers for Medicare & Medicaid Services (CMS) to track all disclosures of the agency’s Personally Identifiable Information (PII). CMS is also required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the Federal Information Security Management Act (FISMA) of 2002 to properly protect all PHI data maintained by the agency and account for the disclosure of PHI. When entities, such as academic, federal or state agency researchers or CMS contractors request CMS PII/PHI data, they enter into a Data Use Agreement (DUA) (OMB# 0938-0734) with CMS. The DUA stipulates that the recipient of CMS data must properly protect the data according to all applicable data security standards and also provide for its appropriate destruction at the completion of the project/study or the expiration date of the DUA. The CMS is permitted to disclose CMS data for research purposes to organizations that have been approved through the research data request process. To qualify to receive CMS data, requesting organizations must compile a data request packet. The data request packet's primary components are the Data Use Agreement (DUA) and the Data Management Plan Self-Attestation Questionnaire (DMP SAQ). The DMP SAQ is a technical, evidence-based questionnaire that DUA users must complete as part of the data request packet. The DMP SAQ will enable CMS to evaluate researcher data systems to ensure that CMS data are adequately secured and appropriately protected, as per the Privacy Act and the HIPAA Privacy Rule. The DMP SAQ also allows CMS to measure compliance through the implementation of security and privacy controls as outlined in the National Institute of Standards and Technology (NIST) Special Publication 800-53 and the Centers for Medicare & Medicaid Services (CMS) Information Security and Acceptable Risk Safeguards (ARS).

US Code: 5 USC USC 552(a) Name of Law: The Privacy Act of 1974

Not associated with rulemaking

  85 FR 78855 12/07/2020
86 FR 10106 02/18/2021

IC Title Form No. Form Name
Data Management Plan Self-Attestation Questionnaire CMS-10733 DMP SAQ

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,000 0 0 0 0 1,000
Annual Time Burden (Hours) 1,500 0 0 0 0 1,500
Annual Cost Burden (Dollars) 0 0 0 0 0 0

Stephan McKenzie 410 786-1943 [email protected]


On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

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