Information Collection

Data Management Plan Self-Attestation Questionnaire (DMP SAQ)

IC 253071 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 Data Management Plan Self-Attestation Questionnaire (DMP SAQ)	Form and Instruction
Form CMS-R-235 Data Management Plans Self Attestation Questionnaire (DMP SAQ) Data Management Plan Self-Attestation Questionnaire (DMP SAQ)	Form and Instruction
CMS-R-235 Data Management Plans Self Attestation Questionnaire (DM DMP SAQ_5.1.docx	Form and Instruction
CMS-R-235 Data Management Plans Self Attestation Questionnaire (DM DMP SAQ_5.1.docx	Form and Instruction
DMP-SAQ 5.1 REDLINE.pdf Track Change - DMP SAQ	IC Document
DMP-SAQ 5.1 REDLINE.pdf Track Change - DMP SAQ	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: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-235				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

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	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	1,500	1,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - DMP SAQ		05/23/2025
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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