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

(CMS-10569) Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

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:

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

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 %

	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

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.