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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-235 Forms used to update the DUA Information	Form and Instruction
Form CMS-R-235 Data Use Agreement (DUA) Signature Addendum Forms used to update the DUA Information	Form and Instruction
Form CMS-R-235 DUA Update to Existing Data Use Agreement Forms used to update the DUA Information	Form and Instruction
Form CMS-R-235 DUA Certificate of Disposition 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

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-235	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	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 %

table that charts list of burden
	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

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.

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