Data Management Plan Self-Attestation Questionnaire (DMP SAQ)

Use Agreement (DUA) Limited Data Set (LDS) Forms Research Identifiable Files (FIF) Forms (CMS-R-235)

Documents and Forms

Document Name Document Type
Form CMS-R-235 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
DMP-SAQ 5.1 REDLINE.pdf Track Change - DMP SAQ IC Document
Form Fields .docx IT system - Data collection fields IC Document

Information Collection (IC) Details

IC Title:	Data Management Plan Self-Attestation Questionnaire (DMP SAQ)	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	CMS-R-235	Data Management Plans Self Attestation Questionnaire (DMP SAQ)	DMP SAQ_5.1.docx		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 %

	Requested	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

Title	Document	Date Uploaded
Track Change - DMP SAQ	DMP-SAQ 5.1 REDLINE.pdf	05/23/2025
IT system - Data collection fields	Form Fields .docx	05/29/2025

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