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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.