HCUP Application Form

Online Application Order Form for Products from the Healthcare Cost and Utilization Project (HCUP)

Documents and Forms

Document Name Document Type
Form Form #1 HCUP Application Form Form and Instruction
Form #1 Attachment A -- Online Application Order Form for Produc FIRST PAGE Online Application Order Form-Products from-HCUP 2019_v3.docx www.distributor.hcup-us.ahrq.gov/SpecialPages/Shoppingcart.aspx Form and Instruction
Form #1 Attachment A -- Online Application Order Form for Produc FIRST PAGE Online Application Order Form-Products from-HCUP 2019_v3.docx www.distributor.hcup-us.ahrq.gov/SpecialPages/Shoppingcart.aspx Form and Instruction
2 Data Use Agreement 360_slide_OFF_Normal.svg www.hcup-us.ahrq.gov/DUA/dua/index.html Form and Instruction
2 Data Use Agreement 360_slide_OFF_Normal.svg www.hcup-us.ahrq.gov/DUA/dua/index.html 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	Attachment A -- Online Application Order Form for Products	FIRST PAGE Online Application Order Form-Products from-HCUP 2019_v3.docx	https://www.distributor.hcup-us.ahrq.gov/SpecialPages/Shoppingcart.aspx	Yes	Yes	Fillable Fileable
Form and Instruction	2	Data Use Agreement	360_slide_OFF_Normal.svg	https://www.hcup-us.ahrq.gov/DUA/dua/index.html	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,800	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,800	1,300	500
Annual IC Time Burden (Hours)	900	650	250
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.