Information Collection

Data Use Agreement

IC 191668 under ICR 202512-0935-004 · OMB 0935-0162.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form # 2 Data Use Agreement	Form and Instruction
Form Form # 2 Attachment B: Hospital Data Use Agreement Data Use Agreement	Form and Instruction
Form # 2 Attachment B: Hospital Data Use Agreement Attachment B - Hospital Data Use Agreement.pdf	Form and Instruction
Form # 2 Attachment B: Hospital Data Use Agreement Attachment B - Hospital Data Use Agreement.pdf	Form and Instruction

IC Title:

Data Use Agreement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	Form # 2				Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 340

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: 0 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-340	340
Annual IC Time Burden (Hours)	-17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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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