Information Collection

Limited Data Set Data Use Agreement (DUA)

IC 253070 under ICR 202505-0938-012 · OMB 0938-0734.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-235 Limited Data Set Data Use Agreement (DUA)	Form and Instruction
Form CMS-R-235 Limited Data Set Data Use Agreement (DUA) Limited Data Set Data Use Agreement (DUA)	Form and Instruction
Form CMS-R-235 LDS DUA Signature Addendum_ Limited Data Set Data Use Agreement (DUA)	Form and Instruction
Form CMS-R-235 LDS DUA Request Application Limited Data Set Data Use Agreement (DUA)	Form and Instruction
CMS-R-235 Limited Data Set Data Use Agreement (DUA) LDS DUA .docx	Form and Instruction
CMS-R-235 Limited Data Set Data Use Agreement (DUA) LDS DUA .docx	Form and Instruction
CMS-R-235 LDS DUA Signature Addendum_ LDS DUA Signature Addendum_508.pdf	Form and Instruction
CMS-R-235 LDS DUA Signature Addendum_ LDS DUA Signature Addendum_508.pdf	Form and Instruction
CMS-R-235 LDS DUA Request Application Attachment A - LDS DUA Request Application .docx	Form and Instruction
CMS-R-235 LDS DUA Request Application Attachment A - LDS DUA Request Application .docx	Form and Instruction
LDS-DUA REDLINE.pdf Track Change - LDS DUA	IC Document
LDS-DUA REDLINE.pdf Track Change - LDS DUA	IC Document
LDS Attachment A_JobAid.pdf LDS_JobAid	IC Document
LDS Attachment A_JobAid.pdf LDS_JobAid	IC Document
LDS Signature Addendum_JobAid.pdf LDS Signature Addendum_JobAid	IC Document
LDS Signature Addendum_JobAid.pdf LDS Signature Addendum_JobAid	IC Document
Form Fields .docx IT system - data collection fields	IC Document
Form Fields .docx IT system - data collection fields	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 Printable
Form and Instruction	CMS-R-235	Yes	Yes	Fillable Printable
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: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	150	350
Annual IC Time Burden (Hours)	210	35	175
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - LDS DUA		05/23/2025
LDS_JobAid		05/27/2025
LDS Signature Addendum_JobAid		05/27/2025
IT system - data collection fields		05/29/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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