Information Collection

Forms used to update the DUA Information

IC 253069 under ICR 202204-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-R-235 Forms used to update the DUA Information Form and Instruction
CMS-R-235 Data Use Agreement (DUA) Signature Addendum Form 0235a Addendum.pdf Form and Instruction
CMS-R-235 Data Use Agreement (DUA) Signature Addendum Form 0235a Addendum.pdf Form and Instruction
CMS-R-235 DUA Update to Existing Data Use Agreement cms-r-0235u.pdf Form and Instruction
CMS-R-235 DUA Update to Existing Data Use Agreement cms-r-0235u.pdf Form and Instruction
CMS-R-235 DUA Certificate of Disposition l. COD-DUAForm-final.pdf Form and Instruction
CMS-R-235 DUA Certificate of Disposition l. COD-DUAForm-final.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Forms used to update the DUA Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-235	Data Use Agreement (DUA) Signature Addendum	Form 0235a Addendum.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	DUA Update to Existing Data Use Agreement	cms-r-0235u.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	DUA Certificate of Disposition	l. COD-DUAForm-final.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,600	5,600
Annual IC Time Burden (Hours)	952	952
Annual IC Cost Burden (Dollars)	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.