Information Collection

HCUP Application Form

IC 204300 under ICR 202508-0935-001 · OMB 0935-0206.

Documents and Forms

Document Name Document Type
Form 1 HCUP Application Form Form and Instruction
Form 1 Attachment A- HCUP DUA Agreement Training Course HCUP Application Form Form and Instruction
Form 2 HCUP DUA for the Nationwide Databases HCUP Application Form Form and Instruction
Form 3 HCUP DUA for the State Databases HCUP Application Form Form and Instruction
Form 4 Online application form HCUP Application Form Form and Instruction
1 Attachment A- HCUP DUA Agreement Training Course Attachment A - HCUP Data Use Agreement Training.docx hcup-us.ahrq.gov/tech_assist/dua.jsp Form and Instruction
1 Attachment A- HCUP DUA Agreement Training Course Attachment A - HCUP Data Use Agreement Training.docx hcup-us.ahrq.gov/tech_assist/dua.jsp Form and Instruction
2 HCUP DUA for the Nationwide Databases Attachment B - NationwideDUA.pdf hcup-us.ahrq.gov/team/NationwideDUA.jsp Form and Instruction
2 HCUP DUA for the Nationwide Databases Attachment B - NationwideDUA.pdf hcup-us.ahrq.gov/team/NationwideDUA.jsp Form and Instruction
3 HCUP DUA for the State Databases Attachment C - StateDUA.pdf hcup-us.ahrq.gov/team/StateDUA.jsp Form and Instruction
3 HCUP DUA for the State Databases Attachment C - StateDUA.pdf hcup-us.ahrq.gov/team/StateDUA.jsp Form and Instruction
4 Online Application Order Form Attachment D - Online Application Form.docx cdors.ahrq.gov/ Form and Instruction
4 Online application form Attachment D - Online Application Form revised.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HCUP Application Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	1	Attachment A- HCUP DUA Agreement Training Course	Attachment A - HCUP Data Use Agreement Training.docx	https://hcup-us.ahrq.gov/tech_assist/dua.jsp	Yes	Yes	Fillable Fileable
Form and Instruction	2	HCUP DUA for the Nationwide Databases	Attachment B - NationwideDUA.pdf	https://hcup-us.ahrq.gov/team/NationwideDUA.jsp	Yes	Yes	Fillable Fileable
Form and Instruction	3	HCUP DUA for the State Databases	Attachment C - StateDUA.pdf	https://hcup-us.ahrq.gov/team/StateDUA.jsp	Yes	Yes	Fillable Fileable
Form and Instruction	4	Online application form	Attachment D - Online Application Form revised.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: Online Application Ordering for HCUP Products From the Healthcare Cost and Utilization Project (HCUP)	FR Citation: 78 FR 32654

Number of Respondents: 1,800	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,800	0	1,800
Annual IC Time Burden (Hours)	1,050	150	900
Annual IC Cost Burden (Dollars)	51,250	51,250	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.

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