Information Collection

Limited Data Set Data Use Agreement (DUA)

IC 253070 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⚠️ Notice: This information collection may be referencing outdated material.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 Limited Data Set Data Use Agreement (DUA) Form and Instruction
CMS-R-235 Limited Data Set Data Use Agreement (DUA) CMS-R-0235L oeda.pdf Form and Instruction
CMS-R-235 Limited Data Set Data Use Agreement (DUA) CMS-R-0235L oeda.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Limited Data Set Data Use Agreement (DUA)	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-235	Limited Data Set Data Use Agreement (DUA)	CMS-R-0235L oeda.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 350	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	350	350
Annual IC Time Burden (Hours)	175	175
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.