Information Collection

Hcup Dua

IC 204302 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⚠️ Notice: This information collection may be referencing outdated material.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:

2025-09-10 - Reinstatement with change of a previously approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 HCUP DUA	Form and Instruction
Form Form #1 NIS Data Use Agreement HCUP DUA	Form and Instruction
Form Form #2 KID Data Use Agreement HCUP DUA	Form and Instruction
Form Form #3 NEDS Data Use Agreement HCUP DUA	Form and Instruction
Form Form #4 SID Data Use Agreement HCUP DUA	Form and Instruction
Form Form #5 SASD Data Use Agreement HCUP DUA	Form and Instruction
Form Form #6 SEDD Data Use Agreement HCUP DUA	Form and Instruction
Form 1 Online Application Order Form HCUP DUA	Form and Instruction
Form #1 NIS Data Use Agreement NIS Data Use Agreement.docx	Form and Instruction
Form #1 NIS Data Use Agreement NIS Data Use Agreement.docx	Form and Instruction
Form #2 KID Data Use Agreement KID Data Use Agreement.docx	Form and Instruction
Form #2 KID Data Use Agreement KID Data Use Agreement.docx	Form and Instruction
Form #3 NEDS Data Use Agreement NEDS Data Use Agreement.docx	Form and Instruction
Form #3 NEDS Data Use Agreement NEDS Data Use Agreement.docx	Form and Instruction
Form #4 SID Data Use Agreement SID Data Use Agreement.docx	Form and Instruction
Form #4 SID Data Use Agreement SID Data Use Agreement.docx	Form and Instruction
Form #5 SASD Data Use Agreement SASD Data Use Agreement.docx	Form and Instruction
Form #5 SASD Data Use Agreement SASD Data Use Agreement.docx	Form and Instruction
Form #6 SEDD Data Use Agreement SEDD Data Use Agreement.docx	Form and Instruction
Form #6 SEDD Data Use Agreement SEDD Data Use Agreement.docx	Form and Instruction
1 Online Application Order Form FIRST PAGE Online Application Order Form-Products from-HCUP 2019_v3.docx	Form and Instruction
1 Online Application Order Form FIRST PAGE Online Application Order Form-Products from-HCUP 2019_v3.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

HCUP DUA

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	Form #1	NIS Data Use Agreement	NIS Data Use Agreement.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #2	KID Data Use Agreement	KID Data Use Agreement.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #3	NEDS Data Use Agreement	NEDS Data Use Agreement.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #4	SID Data Use Agreement	SID Data Use Agreement.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #5	SASD Data Use Agreement	SASD Data Use Agreement.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #6	SEDD Data Use Agreement	SEDD Data Use Agreement.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1	Online Application Order Form	FIRST PAGE Online Application Order Form-Products from-HCUP 2019_v3.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-500	500
Annual IC Time Burden (Hours)	-250	250
Annual IC Cost Burden (Dollars)	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.