RIF Request Packet

Data Use Agreement (DUA) Form, Research Identifiable Files Request Packet Packet, and Data Management Plan (CMS-R-235)

Documents and Forms

Document Name Document Type
Form CMS-R-235 RIF Request Packet Form and Instruction
CMS-R-235 Data Use Agreement (DUA) Form-R-0235 DUA.pdf Form and Instruction
CMS-R-235 Data Use Agreement (DUA) Form-R-0235 DUA.pdf Form and Instruction
CMS-R-235 RIF Request Application 02AttachmentA-RIF-Application-508.docx Form and Instruction
CMS-R-235 RIF Request Application 02AttachmentA-RIF-Application-508.docx Form and Instruction
CMS-R-235 State Agency Supplement 06State-Agency-Supplement-final.pdf Form and Instruction
CMS-R-235 State Agency Supplement 06State-Agency-Supplement-final.pdf Form and Instruction
CMS-R-235 Innovator Supplement 05Innovator-Supplement-final.pdf Form and Instruction
CMS-R-235 Innovator Supplement 05Innovator-Supplement-final.pdf Form and Instruction
CMS-R-235 Collaborator Supplement 04Collaborator-Supplement-final.pdf Form and Instruction
CMS-R-235 Collaborator Supplement 04Collaborator-Supplement-final.pdf Form and Instruction
CMS-R-235 Key Personnel Supplement 03Key-Personnel-final.pdf Form and Instruction
CMS-R-235 Key Personnel Supplement 03Key-Personnel-final.pdf Form and Instruction
CMS-R-235 Amendment Request Form 08RIF-Amendment-final-508.docx Form and Instruction
CMS-R-235 Amendment Request Form 08RIF-Amendment-final-508.docx Form and Instruction

Information Collection (IC) Details

IC Title:	RIF Request Packet	Agency IC Tracking Number:	CMS-R-235

Is this a Common Form? No		IC Status: Modified

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)	Form-R-0235 DUA.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	RIF Request Application	02AttachmentA-RIF-Application-508.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	State Agency Supplement	06State-Agency-Supplement-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Innovator Supplement	05Innovator-Supplement-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Collaborator Supplement	04Collaborator-Supplement-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Key Personnel Supplement	03Key-Personnel-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Amendment Request Form	08RIF-Amendment-final-508.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,705	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	Previously Approved
Annual Number of Responses for this IC	2,705	-6,495	9,200
Annual IC Time Burden (Hours)	1,249	-1,651	2,900
Annual IC Cost Burden (Dollars)	0	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.