Information Collection

57.500 Outpatient Dialysis Center Practices Survey

IC 183544 under ICR 201508-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 CDC 57.500 57.500 Outpatient Dialysis Center Practices Survey	Form and Instruction
CDC 57.500 Outpatient Dialysis Center Practices Survey 57.500_OutpatientDialysisSurv_BLANK.DOCX	Form and Instruction
Att G18_Surveys - Hospital, LTAC, IRF, and Dialysis.pdf Att G18_Surveys--Hospital, LTAC, IRF, and Dialysis	IC Document

IC Title:

57.500 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 and Instruction	CDC 57.500	Outpatient Dialysis Center Practices Survey	57.500_OutpatientDialysisSurv_BLANK.DOCX		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,500

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,500	0	6,500
Annual IC Time Burden (Hours)	13,000	1,625	11,375
Annual IC Cost Burden (Dollars)	368,940	0	368,940

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att G18_Surveys--Hospital, LTAC, IRF, and Dialysis	Att G18_Surveys - Hospital, LTAC, IRF, and Dialysis.pdf	09/09/2015

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