Information Collection

: End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network

IC 217583 under ICR 201511-0938-003 · OMB 0938-1289.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1289 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10569 : End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network	Form and Instruction
CMS-10569 HD Clinical Page 4.6 HD Clinical Page.PNG	Form and Instruction
CMS-10569 PD Clinical Page 4.6 PD Clinical Page.PNG	Form and Instruction
CMS-10569 Clinical Depression Screenshot CW4.8_Clinical Depression_Screenshot.png	Form and Instruction
CMS-10569 Pain Assessment Screenshot CW4.8_Pain Assessment_Screenshot.png	Form and Instruction
HMS Letter to Non-Respondents.docx HMS Letter to non-respondents	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

: End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10569	HD Clinical Page	4.6 HD Clinical Page.PNG	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10569	PD Clinical Page	4.6 PD Clinical Page.PNG	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10569	Clinical Depression Screenshot	CW4.8_Clinical Depression_Screenshot.png	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10569	Pain Assessment Screenshot	CW4.8_Pain Assessment_Screenshot.png	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,264

Number of Respondents for Small Entity: 958

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
Annual Number of Responses for this IC	773,737	773,737
Annual IC Time Burden (Hours)	844,921	844,921
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HMS Letter to non-respondents	HMS Letter to Non-Respondents.docx	07/21/2015

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