Information Collection

57.503 Denominators for Outpatient Dialysis

IC 183560 under ICR 201807-0920-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.503 57.503 Denominators for Outpatient Dialysis	Form
CDC 57.503 Demominators for Dialysis Event Surveillance 57.503_Denom DE_BLANK.DOCX	Form
G9. Dialysis Event.pdf Att G9_Dialysis Event	IC Document

IC Title:

57.503 Denominators for Outpatient Dialysis

Agency IC Tracking Number:

0920-0666

Is this a Common Form? No

IC Status: Unchanged

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	CDC 57.503	Demominators for Dialysis Event Surveillance	57.503_Denom DE_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: 7,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	84,000	84,000
Annual IC Time Burden (Hours)	14,000	14,000
Annual IC Cost Burden (Dollars)	454,440	454,440

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att G9_Dialysis Event	G9. Dialysis Event.pdf	08/01/2016

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