Information Collection

57.104 Patient Safety Component --Outpatient Dialysis Center Practices Survey

IC 183544 under ICR 201112-0920-004 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.104 57.104 Patient Safety Component --Outpatient Dialysis Center Practices Survey	Form
57.104 Patient Safety Component--Outpatient Dialysis Center Pra 57.104_PSOutptDialysisSurv_BLANK.ppt	Form

IC Title:

57.104 Patient Safety Component --Outpatient Dialysis Center Practices Survey

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	57.104	Patient Safety Component--Outpatient Dialysis Center Practices Survey	57.104_PSOutptDialysisSurv_BLANK.ppt		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,500

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	5,500	5,500
Annual IC Time Burden (Hours)	5,500	5,500
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.