View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Dialysis Component	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	0920-20LW	Dialysis Component	covid19 dialysis outpatient module_v6_08112020 (002)kab final.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1317	COVID-19 Module Dialysis Outpatient Facility	Dialysis COVID 19 Reporting Form Clean.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1317	COVID-19 Module Dialysis Outpatient Facility Form 27MAY2021	Dialysis COVID 19 Reporting Form Final 9.5.4 Release.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1317 / Form 57.510	COVID–19 Module - Dialysis Outpatient Facility	09102021_Dialysis COVID 19 Reporting Form Additional Dose 10.0 Release_FINAL.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1317 / Form 57.510	COVID–19 Module - Dialysis Outpatient Facility 25MAY2022	Dialysis COVID 19 Reporting Form May 2022_FINAL.docx	NA	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,700	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 New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	800,800	0	0	0	0	800,800
Annual IC Time Burden (Hours)	200,200	0	0	0	0	200,200
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Instructions for Dialysis Outpatient Facility COVID-19 Module 27MAY2021	COVID Dialysis Module TOIs for Users 9.5.4 Release_Final.docx	05/27/2021
Instructions for Dialysis Outpatient Facility COVID-19 Module 20SEP2021	09102021_Dialysis Module TOIs_REVISED.docx	09/20/2021

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