Information Collection

HCUP Application Form

IC 204300 under ICR 202203-0935-001 · OMB 0935-0206.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0206 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.